Fundamentals of Success Gastrointestinal System
A nurse identifies that a client's colostomy stoma is pale. Which should the nurse do? A. Notify the surgeon. B. Listen for bowel sounds. C. Wash the area with warm water. D. Gently massage around the stoma.
Answer: A Rationale: A. A pale stoma indicates that the circulation to the stoma is compromised, and viability of tissue is questionable without immediate intervention. The primary health-care provider should be notified immediately. B. Although assessing bowel sounds might be done, it is not the priority. Active bowel sounds indicate peristalsis and the presence of flatus in the small intestines, which can occur even if there is an impending problem in the large intestine. C. Washing the area with warm water is inappropriate. This will not improve circulation to the stoma and will waste valuable time. D. Massaging around the stoma is inappropriate. This will not improve circulation and may injure surrounding tissue.
Which outcome of the options presented is most appropriate for a client with perceived constipation? A. Have a bowel movement without the use of a laxative. B. Explain the rationale for the use of laxatives. C. Drink 8 glasses of water per day. D. Defecate every day.
Answer: A Rationale: A. Having a bowel movement without the use of a laxative is the most appropriate outcome for a client with perceived constipation. People with perceived constipation believe that they should have a daily bowel movement and use laxatives, suppositories, enemas, or all of these to achieve this objective. B. Although knowledge is essential, behavioral outcomes determine if a desired outcome is achieved. C. Drinking eight glasses of water per day is an intervention, not a desired outcome. Although desirable for everyone, it does not specifically relate to perceived constipation. D. The need to have a bowel movement every day is unnecessary, unrealistic, and a myth, Patterns of bowel elimination vary considerably, depending on a multitude of factors.
A nurse is teaching a client with a history of constipation about the excessive use of laxatives. Which effect of laxatives should the nurse include as the primary reason why their use should be avoided? A. Weakens the natural response to defecation B. Results in distention of the intestines C. Causes abdominal discomfort D. Precipitates incontinence
Answer: A Rationale: A. Laxatives cause a rapid transit time of intestinal contents. When they are used excessively, the bowel's natural responses to intestinal distention and rectal pressure weaken, resulting in chronic constipation. B. Laxatives increase peristalsis, which helps evacuate the bowel, preventing, not promoting, abdominal distention from flatus or intestinal contents. C. Although excessive laxative use can cause cramping, it is temporary and does not have long-term implications, as does the problem in another option. D. The loss of the voluntary ability to control the passage of fecal or gaseous discharges through the anus (bowel incontinence) is caused by impaired functioning of the anal sphincters or their nerve supply, not excessive laxative use.
A nurse is teaching a client how to irrigate a colostomy. The client asks, "Why is it necessary to use the cone attachment to the irrigation catheter?" What information should the nurse include in a response to this question? A. Stops enema solution from flowing out of the bowel during the procedure B. Prevents prolapse of the bowel during evacuation of the solution C. Dilates the stoma so that the enema tube can be inserted D. Facilitates the elimination of drainage form the colon
Answer: A Rationale: A. The cone advances into the stoma until it effectively fills the opening, which prevents a reflux of solution while the irrigating solution is being instilled. In addition, it helps prevent accidental perforation of the bowel with the rectal catheter. B. A cone will not prevent the prolapse of the bowel. If a prolapse should occur, the surgeon should be notified immediately. C. Using a cone to dilate the stoma so that the enema tube can be inserted is not the purpose of the cone. The catheter is threaded through the center of the cone. D. The cone is removed before the bowel evacuates its contents.
A nurse is caring for a client who is experiencing diarrhea. Which physiological response to diarrhea should the nurse be most concerned about? A. Dehydration B. Malnutrition C. Excoriated skin D. Urinary incontinence
Answer: A Rationale: A. Usually digestive juices of 3.5 to 5.0 L are secreted and reabsorbed by the body daily. With diarrhea, the transit time through the intestine is decreased, interfering with the reabsorption of water, resulting in frequent, loose, watery stools and dehydration. B. Although malnutrition may be related to diarrhea, particularly if it is prolonged, it is neither life-threatening nor the priority in comparison with another option. C. Although the skin may become excoriated in the presence of diarrhea because the enzymes in fecal material can erode the skin, it is neither life-threatening nor the priority in comparison with another option. D. Diarrhea is unrelated to urinary incontinence.
A nurse identifies that a client has tarry stools. Which problems should the nurse conclude that the client is experiencing? A. Upper gastrointestinal bleeding B. Pancreatic dysfunction C. Lactulose intolerance D. Inadequate bile salts
Answer: A Rationale: A. When blood from bleeding in the upper gastrointestinal tract is exposed to the digestive process, the fecal material becomes black (tarry). In addition, ingestion of exogenous iron, red meat, and dark green vegetables can make the stool look black. B. Pancreatic dysfunction results in impaired digestion of fats (by lipase), protein (by trypsin and chymotrypsin), and carbohydrates (by amylase). Pancreatic dysfunction results in pale, foul-smelling, bulky stools, rather than tarry stools. C. A reduction or lack of the secretion of lactase from the wall of the small intestine results in the inability of the body to break down lactose to glucose and galactose. Lactose intolerance causes diarrhea, gaseous distention, and intestinal cramping, not tarry stools. D. Inadequate bile salts result in less bile entering the intestinal tract. The brown color of stool is caused by the presence of stercobilin and urobilin, which are derived from a pigment in bile (bilirubin). The stool will appear clay colored with inadequate bile salts.
A client is attending the health clinic for treatment of hemorrhoids. The nurse reviews the client's history, interviews the client, and performs a focused assessment. Which of the following in the client's history does the nurse conclude may have influenced the development of the hemorrhoids? Select all that apply. CLIENT'S CLINICAL RECORD Client History - Married for 18 years - Has five children between the ages of 7 and 17: three single births and a set of twins - Works as a cashier 4 days a week - Has a history of liver disease Client Interview - Client states that she drinks a glass of wine with dinner. When the hemorrhoids became increasingly painful and a continuous problem, she decided to do something about them. - States she sometimes takes a stool softener when she is constipated. Focused Assessment - Client is 60 pounds more than ideal body weight for height. Three external hemorrhoids are bright red, swollen, and oozing blood. Client states, "My rectal area is itchy and painful." A. Stands for long periods of time at work B. Has had multiple pregnancies C. Tends to have constipation D. Has a disease of the liver E. Is obese
Answer: A, B, C, D, E Rationale: A. Prolonged standing or sitting increases pressure on the hemorrhoidal veins that can cause them to become dilated, enlarged, and inflamed. B. Pregnancy increases intra-abdominal pressure, causing elevated systemic and portal venous pressure, which is transmitted to the anorectal veins. The added pressure of multiple births and having twins aggravates the problem. Eventually, the distended veins separate from the smooth muscle surrounding them, and prolapse of the hemorrhoidal vessels occurs. C. Repeated straining on defecation because of constipation increases intra-abdominal pressure, eventually causing the anorectal veins to distend and become inflamed, resulting in hemorrhoids, Repeated straining causes them to enlarge. D. Portal hypertension is associated with diseases of the liver. The veins of the intestine drain into the branches of the portal vein. Increased pressure in these veins results in distention and inflammation of the hemorrhoidal veins. E. Increased intra-abdominal pressure associated with obesity causes elevated systemic and portal venous pressure, which is transmitted to the anorectal veins. Eventually, the veins distend and become inflamed, resulting in hemorrhoids.
The client is experiencing constipation. Which independent nursing action facilitates defecation of a hard stool? Select all that apply. A. Applying a lubricant to the anus B. Providing a sitz bath after defecation C. Instilling warm mineral oil into the rectum D. Placing a warm, wet washcloth against the perianal area E. Encouraging the client to rock forward and back while defecating
Answer: A, D, E Rationale: A. A lubricant reduces friction, which facilitates the passage of a hard, dry stool through the anus. Nurses are legally permitted to diagnose and treat human responses. Constipation is a human response, and applying a water-soluble lubricant to the anus is an independent function of the nurse. B. A sitz bath requires a primary health-care provider's prescription and is a dependent, not independent, function of the nurse. A sitz bath will not promote the passage of a hard, dry stool, but it may promote hygiene and comfort after the bowel movement. C. An oil-retention enema softens the feces and lubricates the rectum and anus. However, it requires a primary health-care provider's prescription and is a dependent, not independent, function of the nurse. D. A warm, wet washcloth placed against the perianal area may facilitate defecation by relaxing the surrounding muscles and the external sphincter. E. Rocking forward and back when attempting to defecate increases both tension against the abdomen and intra-abdominal pressure; these facilitate the passage of stool from the rectum and anus.
A nurse is collecting a bowel elimination history from a newly admitted client with a medical diagnosis of possible bowel obstruction. Which question takes priority? A. "Do you use anything to help you move your bowels?" B. "When was the last time you moved your bowels?" C. "What color are your usual bowel movements?" D. "How often do you have a bowel movement?"
Answer: B Rationale: A. Although asking if anything is used to help move the bowels may be done, it is not the priority at this time. B. A cardinal sign of a bowel obstruction is the lack of a bowel movement (obstipation). C. Although asking about the color of bowel movements will be done, this information relates more to malabsorption, biliary problems, and gastrointestinal bleeding. D. Although asking how often one has a bowel movement will be done to obtain baseline information about intestinal elimination, it is not specific to the presenting problem.
A nurse performs a physical assessment of a newly admitted client who is incontinent of stool. For which characteristic related to bowel incontinence should the nurse assess the client? A. Frequent, soft stools B. Involuntary passage of stool C. Impaired anal sphincter control D. Greenish-yellow color to the stool
Answer: B Rationale: A. Frequent, soft stools are associated with diarrhea. Diarrhea is loose, liquid stools, increased frequency (three times a day or more) of stools, or both. B. An involuntary passage of stool is a major clinical finding associated with bowel incontinence, which is the state in which an individual experiences a change in usual bowel habits characterized by involuntary passage of stool. C. Impaired anal sphincter control is not a characteristic a nurse can evaluate when performing a physical assessment. D. A greenish-yellow color to the stool is unrelated to bowel incontinence. A green or orange color to the stool indicates intestinal infection.
Which word is specific regarding how a soapsuds enema works on the mucosa of the bowel? A. Dilating B. Irritating C. Softening D. Lubricating
Answer: B Rationale: A. High-volume (not soapsuds) enemas, such as tap-water or saline enemas, work by distending (dilating) the lumen of the intestine. B. Although a soapsuds enema works by increasing the volume in the colon, its unique attribute is that soap is irritating to the intestinal mucosa. Irritation of the mucosa precipitates peristalsis, which facilitates that evacuation of fecal material. C. An oil-retention enema, a small-volume enema, introduces oil into the rectum and sigmoid colon; this softens the feces and lubricates the rectum and anal canal, facilitating defecation. D. An oil-retention enema, not a soapsuds enema, lubricates the rectum and anal canal, facilitating the passage of feces.
A nurse determines that the teaching about a guaiac test of stool is understood when the client states that it identifies the presence of which of the following? A. Ova and paraistes B. Hidden blood C. Bacteria D. Bile
Answer: B Rationale: A. Ova and parasites are identified through microscopic examination of feces, not by the guaiac test. B. Testing the feces for occult blood is called the guaiac test. This test uses a chemical reagent to detect the presence of the enzyme peroxidase in the hemoglobin molecule. Occult blood is obscure (hidden) and may not be visible to the naked eye. C. Bacteria are identified in feces through a stool culture, not by the guaiac test. D. Bile is an expected constituent of fecal material and is not detected with the guaiac test.
A school nurse is planning a health class about bodily functions. Which information should be included regarding the purpose of mucus in the gastrointestinal tract? A. Activates digestive enzymes B. Protects the gastric mucosa C. Enhances gastric acidity D. Emulsifies fats
Answer: B Rationale: A. The presence of fluid or food activates digestive enzymes, not mucus. B. Mucus secreted by mucous membranes and glands is a viscous, slippery fluid containing mucin, white blood cells, water, inorganic salts, and exfoliated cells. Mucin, a mucopolysaccharide, is a lubricant that protects body surfaces from friction and erosion. C. Mucus does not enhance gastric acidity. Gastric acidity enhances digestion. D. The low surface tension of bile salts contributes to the emulsification of fats in the intestine.
Which client statement supports the nurse's conclusion that a client understands the need to reestablish bowel flora after a week of diarrhea? A. "I must wean myself off of the antibiotics one day after my temperature is normal." B. "I should eat a container of yogurt every day for a few days." C. "I have to add rice to my diet in one meal each day." D. "I ought to drink eight glasses of water a day."
Answer: B Rationale: A. Weaning off the antibiotic 1 day after the temperature is normal will not reestablish bowel flora. Discontinuing antibiotics before the full course of therapy is completed can result in a return of the original infection or precipitate the development of a superinfection. B. Yogurt is merely milk that is curdled by the addition of bacteria, specifically Lactobacillus bulgaricus and Streptococcus thermophilus. Eating yogurt helps to restore the bacterial balance of the resident flora of the intestine. C. Although rice helps to limit diarrhea, it will not reestablish bowel flora. D. Although water is essential for all body processes, and to replace fluid lost in the diarrhea, it does not reestablish bowel flora.
A nurse is to administer an oil-retention enema, a tap-water enema, and a return-flow enema to three different clients. Which of the following should be performed with all three enemas? Select all that apply. A. Use between 500 and 1,000 mL of solution. B. Place the client in the left side-lying position. C. Use water-soluble jelly to lubricate the tip of the rectal probe. D. Pull the curtain around the client's bed and drape the client. E. Hold the enema solution a minimum of 12 inches above the anus.
Answer: B, C, D Rationale: A. The amount of solution used depends on the type of enema prescribed. A tap-water enema uses 500 to 1,000 mL of tap water to distend the intestine and promote defecation. An oil-retention enema has 200 to 250 mL of an oil-based solution to soften feces and promote defecation. A return-flow enema begins with approximately 300 to 500 mL of tap water in the enema container. A small volume of the solution (e.g., 150 to 200 mL) is instilled, and the enema container is immediately lowered below the anus to withdraw fluid and gas into the collection container. The purpose of a return-flow enema is to reduce abdominal distention caused by intestinal gas. B. The left side-lying position allows the fluid to flow via the principle of gravity as the fluid follows the normal curve of the anus, rectum, and sigmoid colon. C. Lubrication of the tip of the catheter or probe limits trauma to the mucous membranes of the intestine. D. Enemas require that the client's perianal area be exposed. Pulling the curtain around the client's bed and draping the client provide for client privacy and dignity. E. Oil-retention enemas and hypertonic enemas are administered in small volumes (e.g., 4.5 to 7.8 mL) via a soft-sided container. The container is squeezed and rolled slowly from the distal to the proximal end until empty. With tap-water and soapsuds enemas, the solution is instilled holding the enema container 8 to 12 inches above the anus.
A nurse is caring for a group of clients. Which client factor should the nurse identify as placing a client at risk for bowel incontinence? A. Being ninety years old B. Taking a sedative for sleep C. Disoriented to time, place, and person D. Receiving multiple antibiotic medications
Answer: C Rationale: A. Constipation, not bowel incontinence, is more common in older adults than in other age groups. Constipation in older adults is caused by decreased bowel motility, inadequate hydration, lack of fiber, sedentary lifestyle, misuse of laxatives, and side effects of medications. B. Sedatives depress the central nervous system, which may precipitate constipation, not bowel incontinence. C. When a person is disoriented to time, place, and person, the individual may not have the cognitive ability to perceive and interpret intestinal distention and rectal pressure cues to defecate, resulting in bowel incontinence. D. Antibiotic medications are known for causing diarrhea, not bowel incontinence.
A nurse is assisting a client with a regular bedpan. Which nursing action is essential? Select all that apply. A. Position the client slightly off the back edge of the bedpan. B. Fold the top linen out of the way when putting the client on the bedpan. C. Remain outside the curtains of the bed until the client is done using the bedpan. D. Elevate the head of the bed to the Fowler position after the client is on the bedpan. E. Raise the side rails on both sides of the bed after the client is positioned on the bedpan.
Answer: C, D, E Rationale: A. Positioning a client slightly off the back edge of a regular bedpan is unsafe and uncomfortable. The client should be positioned so that the buttocks rest on, not slightly off of, the smooth, rounded rim of a regular bedpan. B. Folding the top linen out of the way when putting the client on the bedpan is unnecessary. The top linen can be draped over the client in such a way as to promote placement of the bedpan while maintaining the privacy and dignity of the client. C. Remaining outside the curtains of the client's bed while the client is on the bedpan allows the nurse to be in close proximity to the client. The nurse is available to assist the client if needed, and it provides a sense of security for the client. D. Elevating the head of the bed so that the client is in the high-Fowler position assumes the familiar, usual position for having a bowel movement. A vertical position utilizes gravity, and hip flexion raises intra-abdominal pressure, both of which maximize evacuation of feces. E. Raising both side rails provides support on which the client can rest the upper extremities and maintains client safety. Raising the side rails before raising the head of the bed maintains safety.
Which should the nurse do before collecting a stool sample for occult blood? A. Plan to collect the first specimen of the day. B. Obtain a sterile specimen container. C. Wash the client's perianal area. D. Ask the client to void.
Answer: D Rationale: A. Collecting the first specimen of the day is unnecessary. B. Using a sterile specimen container is unnecessary. Medical, not surgical, asepsis should be followed. C. Washing the perineal area is unnecessary. However, the nurse may assist the client to perform perineal hygiene after the stool specimen is obtained. D. Emptying the urinary bladder before attempting to have a bowel movement prevents accidental contamination of the specimen by urine.
While providing a health history, the client tells the nurse, "I have gastroesophageal reflux disease." Which most serious consequence associated with this disorder should the nurse anticipate this client may develop? A. Diarrhea B. Heartburn C. Gastric fullness D. Esophageal erosion
Answer: D Rationale: A. Diarrhea is not associated with gastroesophageal reflux disease (GERD). B. Pain occurring behind the sternum (heartburn) and sore throat are the predominant symptom of GERD. Although these responses are a concern, they can be treated. C. Although feeling full, distended, or bloated can occur with GERD, it is not life-threatening, and the client can be taught interventions to limit its occurrence. D. With GERD, a backflow of the contents of the stomach into the esophagus occurs. Gastric juices are acetic (pH less than 3.5), which can cause erosion of the mucous membranes of the esophagus. Cellular changes in the lining of the esophageal mucosa (Barrett's esophagus) are a risk factor for developing esophageal cancer.
A nurse is assessing a client who has a distended abdomen resulting from flatulence. The client has a prescription for a regular diet and an activity prescription for "out of bed." Which can the nurse do to promote passage of the intestinal gas? A. Instruct the client to increase the amount of fluid intake. B. Suggest that the client avoid cruciferous foods. C. Obtain a prescription for a laxative. D. Encourage the client to ambulate.
Answer: D Rationale: A. Increasing the amount of fluid intake will not facilitate the evacuation of intestinal gas. B. Limiting the intake of cruciferous foods will prevent the development of intestinal gas, not promote its evacuation. C. A laxative is an excessive intervention for a client with flatulence. D. Ambulation increases metabolic activity, which increases intestinal peristalsis. Increased intestinal peristalsis moves intestinal gas toward the anus, where it can be expelled.
A nurse is teaching a client with a cardiac condition to avoid the Valsalva maneuver. Which should the nurse teach the client to do? A. Eat rice several times a week. B. Take a cathartic on a regular basis. C. Attempt to have a bowel movement every day. D. Exhale while contacting the abdominal muscles.
Answer: D Rationale: A. Rice thickens stool, which promotes the development of constipation. Constipation may result in straining on defecation, which employs the Valsalva maneuver. B. Prescribing a cathartic is a dependent, not an independent, function of the nurse. Regular use of a cathartic is contraindicated because it leads to dependence. C. Attempting to have a bowel movement every day may result in straining, which employs the use of the Valsalva maneuver. Also, the client may not need to have a daily bowel movement. D. Exhaling requires the glottis to be open, which prevents the Valsalva maneuver. The Valsalva maneuver is bearing down while holding the breath by closing the glottis, which increases intrathoracic pressure. The Valsalva maneuver briefly interferes with blood flow to the heart. When the glottis opens during exhalation, the pressure is released and a surge of blood flows to the heart, which may precipitate a dysrhythmia in a person with a cardiac condition.
A nurse is performing a physical assessment of a client concerning the gastrointestinal system. Place the following interventions in the order in which they should be performed. 1. Palpate the abdomen. 2. Inspect the anus and perianal area visually. 3. Percuss the abdomen for the quality of sounds. 4. Auscultate the entire abdomen for bowel sounds. 5. Observe the contour and symmetry of the abdomen.
Answer: 5, 2, 4, 3, 1 Rationale: 1. Palpation should occur after less invasive assessment techniques are completed. 2. The anus and the perianal area should be inspected after a less invasive assessment and before other assessment techniques that can alter the results of inspection. 3. Percussion should occur after les invasive techniques but before a more invasive assessment technique that can alter the results of percussion. 4. Auscultation should occur after less invasive assessment techniques and before other more invasive assessment techniques that can alter the results of auscultation. 5. Inspection should occur first before it is the least invasive assessment. the abdomen should be assessed before turning the client, which slightly rearranges the internal organs.
A nurse discourages a client from straining excessively when attempting to have a bowel movement. Which undesirable physiological response is the primary reason why straining on defecation should be avoided? A. Dysrhythmia B. Incontinence C. Fecal impaction D. Rectal hemorrhoid
Answer: A Rationale: A. Straining on defecation requires the person to hold the breath while bearing down (Valsalva maneuver). This maneuver increases the intrathoracic and intracranial pressures, which can precipitate dysrhythmias, brain attack (stroke), and respiratory difficulties; all of these can be life-threatening. B. The loss of the voluntary ability to control the passage of fecal or gaseous discharges through the anus (bowel incontinence) is caused by impaired functioning of the anal sphincters or their nerve supply, not straining on defecation. C. Fecal impaction is caused by the accumulation and prolonged retention of fecal material in the large intestine, not straining on defecation. D. Although straining on defecation can contribute to the formation of hemorrhoids, this is not the primary reason straining on defecation is discouraged. Hemorrhoids, although painful, are not life-threatening.
A nurse is caring for a group of clients with a variety of gastrointestinal problems. Which of the following can cause both diarrhea and constipation? Select all that apply. A. Inability to perceive bowel cues B. Cancer of the large intestines C. Side effects of medications D. High-solute tube feedings E. Increased metabolic rate
Answer: B, C Rationale: A. An inability to perceive bowel cues for defecation results in a lack of response that further weakens the defecation reflex, ultimately causing constipation, not diarrhea. B. Cancer of the large intestine can cause constipation, diarrhea, alternating constipation and diarrhea, or all of these. The mass in the intestinal lumen may partially or totally obstruct the passage of stool, resulting in a condition that appears to be constipation. The leakage of stool around an intestinal tumor/lesion results in a condition that appears to be diarrhea. C. Medications, depending on their physiological action, side effects, and toxic effects, can cause either constipation or diarrhea. D. A high-solute tube feeding has a greater osmotic pressure than surrounding interstitial tissue; it draws fluid into the gastrointestinal tract, which may result in diarrhea, not constipation. E. An increased metabolic rate will increase peristalsis and possibly result in an increased frequency of the passage of stools, not constipation.
A nurse should use a fracture bedpan for clients with which condition? Select all that apply. A. Below the knee amputation B. Peripheral vascular disease C. Spinal cord injury D. Dementia E. Obesity
Answer: C Rationale: A. A regular bedpan is appropriate for a client who has a below the knee amputation. B. A regular client bedpan is appropriate for a client with peripheral vascular disease. C. A fracture bedpan has a low back that promotes functional alignment of the client's lower back while on the bedpan. D. A regular bedpan is appropriate for a client with dementia. E. A regular bedpan is appropriate for a client who is obese.
A primary health-care provider prescribes a tap-water enema for a client. The client asks about the purpose of the enema. When specific information about the purpose of a tap-water enema should be included in the nurse's response? A. "It reduces abdominal gas." B. "It drains the urinary bladder." C. "It empties the bowel of stool." D. "It limits nausea and vomiting."
Answer: C Rationale: A. A return-flow enema (Harris flush, Harris drip), not a tap-water enema, helps eliminate intestinal gas. B. A urinary retention catheter (Foley), not a tap-water enema, drains the urinary bladder of urine. C. A tap-water enema instills fluid into the large intestine; the pressure of this volume stimulates peristalsis, causing the colon to evacuate stool. D. A tap-water enema will not affect nausea and vomiting; taking nothing by mouth or medication can be used to limit nausea and vomiting.
A nurse is caring for a client with an intestinal stoma. Which intervention is most important? A. Cleansing the stoma with cool water B. Spraying an air-freshening deodorant in the room C. Selecting a bag with an appropriate-size stomal opening D. Wearing sterile, nonlatex gloves when caring for the stoma
Answer: C Rationale: A. Although a stoma can be cleaned with water as long as it is not the extremes of hot or cold, it is not the priority. B. Although spraying an air-freshening deodorant in the room might be done, it is not the priority. C. The opening of the appliance must be large enough to encircle the stoma to within 1/8 inch to protect the surrounding tissue from the enzymes present in the intestinal discharge without impinging on the stoma. Pressure against the stoma can damage delicate mucosal tissue or impede circulation to the stoma, both of which can impair the visibility of the stoma. D. Clean, not sterile, gloves should be worn when caring for a stoma. Medical, not surgical, asepsis should be practiced. Latex or nonlatex gloves can be worn as long as the client or nurse does not have a latex allergy.
A nurse is implementing a prescribed bowel preparation for a client who is scheduled for a colonoscopy. Which is the most serious consequence that is prevented by an effective bowel preparation? A. Psychological stress B. Wasted expense C. Misdiagnosis D. Discomfort
Answer: C Rationale: A. Although psychological stress is a serious consequence, it is not life-threatening. B. Although a canceled or repeated colonoscopy may incur a wasted expense, this consequence is not life-threatening. A test may be canceled or performed a second time if the client has an ineffective bowel preparation. C. Fecal material in the intestines can interfere with the visualization, collection, and analysis of data obtained through a colonoscopy, resulting in diagnostic errors. D. Although discomfort may occur, it is not the most serious outcome of an inappropriate preparation for a colonoscopy.
Which statement by a client with an ileostomy alerts the nurse to the need for further education? A. "I don't expect to have much of a problem with fecal odor from the stoma." B. "I will have to take special precautions to protect my skin around the stoma." C. "I am going to have a bowel movement every morning when I irrigate the stoma." D. "I should avoid gas-forming foods like beans to limit funny noises from the stoma."
Answer: C Rationale: A. The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the large intestine. An ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum). B. Cleansing the skin, skin barriers, and a well-fitted appliance are precautions to protect the skin around an ileostomy stoma. The drainage from an ileostomy contains enzymes that can damage the skin. C. This statement is inaccurate in relation to an ileostomy and indicates that the client needs more teaching. An ileostomy produces liquid fecal drainage, not formed stool that requires irrigation. D. An ileostomy stoma does not have a sphincter that can control the flow of flatus or drainage, resulting in noise.
A client is admitted with lower gastrointestinal tract bleeding. Which characteristic of the client's stool should the nurse assess for the supports this medical diagnosis? A. Tarry stool B. Orange stool C. Green mucoid stool D. Bright red-tinged stool
Answer: D Rationale: A. Tarry stools indicate upper gastrointestinal bleeding. B. Orange stools indicate the presence of infection. C. Green mucoid stools indicate the presence of infection. D. Bright red-tinged stools are the cardinal sign of lower gastrointestinal bleeding. When bleeding occurs close to the anus, enzymes have not digested the blood, so the blood has not turned black.
