Implement and Take Action; Evaluate
Which action would the nurse take for a patient with a newly formed bowel diversion? Perform stoma care him- or herself. Instruct patient to empty the bag when three-quarters full. Make sure there is at least ¼ inch around appliance and stoma. Apply the pouch over several skinfolds.
Perform stoma care him- or herself. The nurse would not delegate this skill if the stoma is new or complications are present; thus, the nurse would perform stoma care because the patient has a new bowel diversion.
Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient's bowel elimination needs? Remove a fecal impaction in a young adult. Record intake and output for a frail older adult. Insert a nasogastric tube in a teenager. Administer a medicated enema to a middle-aged adult.
Record intake and output for a frail older adult. The nurse can delegate recording intake and output to the UAP.
Place the steps of ostomy care for a patient in the correct order. Cleanse the area surrounding the stoma. Remove and dispose of the used ostomy pouch. Apply the new pouch. Prepare the new pouch to fit stoma. Assess the integrity of the stoma and peristomal skin. Measure the stoma.
Remove and dispose of the used ostomy pouch. Cleanse the area surrounding the stoma. Assess the integrity of the stoma and peristomal skin. Measure the stoma. Prepare the new pouch to fit stoma. Apply the new pouch.
Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant? Psyllium Docusate Mineral oil Senna
Senna The nurse would observe senna on the MAR. Senna is a type of stimulant cathartic laxative.
Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health? Select all that apply. "Because I am 50, I need to have a fecal occult blood test every year." "Because I am 60, a sample of my stool should be examined for parasites every 5 years." "Because I have a family history of colorectal cancer, I should have sigmoidoscopy or colonoscopy screening every 5 to 10 years." "Because I am 25 years old and have a family history of colorectal cancer, sigmoidoscopy or colonoscopy screening should begin this year." "Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now."
"Because I am 50, I need to have a fecal occult blood test every year." This statement reflects the recommended screening guidelines for fecal occult blood testing and indicates successful teaching. "Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now." Sigmoidoscopy and colonoscopy screening for colorectal polyps and early signs of cancer begins at age 45 to 50 for most people. This statement indicates successful teaching
Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent? "This medication speeds up my intestinal motility to clear the stool from my system." "I should take the medicine for no more than 72 hours." "It's good to know that these drugs are not habit-forming." "I need to carefully insert the suppository into my rectum using a clean disposable glove."
"I should take the medicine for no more than 72 hours." This statement indicates patient understanding. It is recommended that a patient limit use of opioid antidiarrheal drugs to 48 to 72 hours.
After how many enemas would the nurse notify the health care provider when the patient's bowel return for cleansing enemas is still brown? Record your answer as a whole number. ______ enemas
3 For enemas until clear (cleansing enema), the nurse should not give more than three enemas consecutively.
For which patient would the nurse obtain this piece of equipment? A completely bedbound patient A patient who is unable to ambulate even with assistance A patient requiring a lift device for transfer to a chair A patient who has difficulty ambulating to the bathroom
A patient who has difficulty ambulating to the bathroom A patient who has difficulty ambulating to the bathroom would be a good candidate for a bedside commode.
Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient? Select all that apply. Assisting the patient onto the bedpan Assisting the patient to the bathroom Ensuring that nonskid shoes/socks are in place Placing the patient in Sims position on left side Placing the patient in a position of comfort for the specific enema retention time
Assisting the patient to the bathroom Because the patient can walk to the bathroom, the nurse would assist the patient to the bathroom. Ensuring that nonskid shoes/socks are in place For safety, the patient would wear nonskid footwear to prevent falls.
Which action would the nurse take first when there is no movement of fluid in the patient's nasogastric tube and the patient's abdomen is becoming distended? Notify the health care provider. Irrigate the tube with normal saline. Have the patient swallow using a glass of water. Determine the patient's last bowel movement.
Irrigate the tube with normal saline. The nurse would irrigate the tube with normal saline first when there is no movement of fluid in the nasogastric tube and the patient's abdomen is becoming distended.
Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration? Select all that apply. Fever Increased output of gastric fluid Congested lung sounds Shortness of breath Decreased peristalsis
Fever Temperature (fever) occurs with aspiration. Congested lung sounds Lung congestion or congested lung sounds occur with aspiration. Shortness of breath Dyspnea, or shortness of breath, occurs with aspiration.
For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance? Gastric lavage Enteral feedings Gastrointestinal tract decompression Medication administration
Gastric lavage A large-bore nasogastric tube allows the stomach to be irrigated with fluids to flush out poisons and blood.
Which assessment cues would alert the nurse that the patient with diarrhea is declining? Select all that apply. Has two more episodes of liquid stools Exhibits dry mucous membranes Exhibits poor skin turgor Has the same amount of watery stools Has documentation of a formed stool
Has two more episodes of liquid stools Having two more episodes of liquid stools indicates the patient is declining. Exhibits dry mucous membranes Developing signs of dehydration (exhibiting dry mucous membranes) indicates the patient is declining. Exhibits poor skin turgor Developing signs of dehydration (exhibiting poor skin turgor) indicates the patient is declining.
Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating? Select all that apply. Heart rate drops to 56 beats/min Respiratory rate of 16 breaths/min Removal of hard stool Blood pressure elevates from 120/60 to 142/66 mm Hg Continuation of liquid oozing
Heart rate drops to 56 beats/min A heart rate below 60 beats/min indicates the patient is declining/deteriorating. Blood pressure elevates from 120/60 to 142/66 mm Hg Blood pressure elevation by 20 to 40 mm Hg (120 to 142 mm Hg) indicates the patient is declining/deteriorating.
Which action would the nurse take when the unlicensed assistive personnel (UAP) obtains this piece of equipment for a patient with a hip fracture? Go with the UAP to help position the patient correctly on the piece of equipment. Inform the UAP to gently place the patient on the piece of equipment. Help the UAP obtain the correct piece of equipment. Tell the UAP to use two people to place the patient on the piece of equipment.
Help the UAP obtain the correct piece of equipment. The nurse would help the UAP obtain the correct piece of equipment, a fracture pan. The UAP would use a fracture bedpan, not a standard bedpan for a patient with a hip fracture.
Based on the image below, which type of enema is the nurse administering to a patient? Hypertonic Isotonic Hypotonic Tap water
Hypertonic The image is a commercial enema preparation, a hypertonic/small volume, which uses osmotic pressure to draw fluid from interstitial spaces into the colon.
Which action would the nurse take if there are concerns during administration of the enema? If the patient cannot hold the enema solution, place the patient on a bedpan. If the patient reports cramping, raise the enema bag to a height above 18 inches (43 cm). If there is resistance upon insertion of the enema tube, insert the enema tube upon inhalation. If the sphincter is tight, make sure the temperature of the solution is over 105°F (40.5°C).
If the patient cannot hold the enema solution, place the patient on a bedpan. If the patient cannot retain the enema, place the patient on a bedpan.
Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy? Select all that apply. Measure the stoma. Assess the pouch seal. Irrigate the ostomy with water using a catheter. Gently wash the stoma and peristomal area with water. Provide a 30-minute "resting" time before applying the new pouch.
Measure the stoma. Careful measurement of the stoma is necessary to prevent injury to the stoma or surrounding skin. Assess the pouch seal. The pouch is assessed to make sure the seal is secure to prevent leakage and potential skin breakdown. Gently wash the stoma and peristomal area with water. It is important to wash the stoma and surrounding area to prevent skin irritation and to enhance adherence of the pouch.
Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating? Beefy red Moist, red Moist, blue Reddish pink
Moist, blue A moist, blue stoma indicates the patient is declining/deteriorating, and the health care provider needs to be notified.
Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated? Select all that apply. Monitor intake and output. Offer milkshakes. Encourage apple juice. Restrict fluids. Weigh daily. Assess skin turgor.
Monitor intake and output. The nurse would monitor intake and output for a patient with diarrhea and dehydration. Weigh daily. The nurse would weigh the patient daily, especially because dehydration is developing. Assess skin turgor. The nurse would assess skin turgor, especially because dehydration is developing.
Which action would the nurse take for a patient whose ostomy stoma is speckled white? Obtain adhesive remover. Apply a skin barrier. Notify the health care provider. Document the normal findings.
Notify the health care provider. The health care provider is notified because the findings indicate the patient has probably developed a fungal infection.
For which constipated patient would the nurse administer a laxative? One who is experiencing nausea One who has been vomiting One who is allergic to opiates One who reports abdominal pain of unknown origin
One who is allergic to opiates Laxatives are not opiate-based drugs; therefore the nurse would administer the laxative to this patient.
For which patient would the nurse likely insert the nasogastric (NG) tube pictured here? One who needs a one-lumen tube One who needs gastric decompression One who requires long-term enteric feedings One who requires a Levine tube
One who needs gastric decompression The nurse would insert the tube in this patient because the tube depicted is a Salem sump tube, the preferred type of NG tube for decompression of the stomach.
Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health? Select all that apply. Fluids should be at a tepid temperature. Ambulating 5 to 10 minutes each day increases digestion. Walking stimulates intestinal muscle contraction. Exercise should wait until at least 2 hours after eating to prevent cramping. Usually 6 to 8 glasses of fluid should be consumed per day.
Walking stimulates intestinal muscle contraction. The nurse would include this information because aerobic exercise, like walking, stimulates contraction of intestinal muscles. Usually 6 to 8 glasses of fluid should be consumed per day. The nurse would include this information because the patient needs 6 to 8 glasses of fluid to keep feces soft.
