YOOST EAQ CHP 40

A nurse is caring for a patient who has a colostomy. When assessing the color of the stoma, which color indicates the stoma is healthy? 1 Reddish pink 2 Purple 3 Blue 4 Brown 5 Black

1

The registered nurse is reviewing the procedure of administering an enema with a co-worker. Which statement made by the co-worker requires further teaching? 1 "I should fill the enema bag with a cool solution." 2 "I should explain the procedure to the patient." 3 "I should lubricate the tip of the tubing 3 inches." 4 "I should put the patient in a left side-lying position."

1

Which condition is indicated by abdominal pain and hyperactive bowel sounds in a patient? 1 Onset of diarrhea 2 Fecal impaction 3 Constipation 4 Paralytic ileus

1

Which medication does the nurse suspect is the cause of whitish discoloration of stools? 1 Antacids 2 Iron salts 3 Cathartics 4 Calcium supplements

1

The nurse is caring for a 78-year-old man with diarrhea. Which problem is the most important to consider? 1 Malnutrition 2 Dehydration 3 Skin breakdown 4 Incontinence

2

A patient with constipation reports having blurred vision. The nurse assesses that the patient is straining during defecation. What does the nurse suspect as the cause of these symptoms? 1 A decrease in intracranial pressure 2 An increase in intraocular pressure 3 A decrease in intrathoracic pressure 4 An increase in arterial blood pressure

2 Straining during defecation causes an increase in intraocular pressure, which can result in papilledema. Exhalation through closed windpipe, which is referred to as the Valsalva maneuver, also occurs during defecation, which results in increased intrathoracic pressure. Dizziness may occur due to a decrease in arterial blood pressure. Straining can also lead to increased intracranial pressure

The nurse finds that a patient complaining of constipation has a history of a myocardial infarction and is taking antianginal drugs. Which nursing intervention would help prevent cardiac complications in this patient? 1 Obtain and record daily weights from the patient 2 Instruct the patient not to strain while defecating 3 Explain how to ignore the urge to defecate 4 Encourage the patient to consume lukewarm liquids

2 Straining may cause bradycardia by stimulating the Valsalva maneuver. This can trigger another myocardial infarction. The Valsalva maneuver is performed by holding one's breath while bearing down. This closes the windpipe and increases intrathoracic pressure. This maneuver causes a fast rise in blood pressure followed by a fall in arterial blood pressure. This can result in dizziness, blurred vision, and fainting. A patient with diarrhea should be weighed daily to monitor fluid and electrolyte balance and prevent life-threatening fluid loss. Ignoring the urge to defecate allows increased water absorption in the colon, making feces hard and difficult to expel and may lead to straining. Warm and cold liquids, rather than lukewarm liquids, stimulate peristalsis and aid in defecation, thus reducing the need to strain while defecating.

The nurse is caring for a patient with a colostomy. Which intervention is most important? 1 Cleansing the stoma with hot water 2 Inserting a deodorant tablet in the stoma bag 3 Selecting a bag with an appropriate-sized stoma opening 4 Wearing sterile gloves while caring for the stoma

3

The nurse is taking a health history of a newly admitted patient with a diagnosis of rule out bowel obstruction. Which is the priority question to ask the patient? 1 Describe your bowel movements. 2 How often do you have a bowel movement? 3 When was the last time you moved your bowels? 4 Do you routinely use stool softeners, laxatives, or enemas?

3

The nurse understands that when comparing nasogastric tubes used for gastric decompression, a Salem sump is preferred because: 1 It minimizes the risk of a bowel obstruction. 2 It ensures drainage of the intestines. 3 It has two lumens. 4 It has one lumen.

3

Which complication does the nurse monitor for in a pregnant patient who is taking prenatal vitamin tablets with iron? 1 Diarrhea 2 Flatulence 3 Constipation 4 Incontinence

3

Which statement by a patient with ileostomy indicates a need for additional teaching? 1 "I'll change the pouch before it begins to leak." 2 "I can eat dairy products." 3 "I don't need to monitor my fluid intake." 4 "I won't need to buy new clothing that better accommodates the pouch."

3

The nurse explains the procedure for a series of lower gastrointestinal scans to a patient with a colonic ulcer. Which statement made by the nurse indicates the need for additional teaching? 1 "You will change positions frequently during the scan." 2 "You should have a liquid diet for 2 days before the test." 3 "You should limit fluid intake for several days after the test." 4 "You will be administered an enema before the procedure."

3 Barium alters bowel function and can lead to an impaction; therefore, the nurse instructs the patient to increase fluid intake to prevent this from happening. The nurse instructs the patient to change positions as directed during the procedure in order to obtain different views of the colon. Food interferes with the results; therefore, the nurse instructs the patient to consume a liquid diet for 2 days before the test. For clear visualization of the colonic anatomy, it is essential to empty the bowel; therefore, the nurse instructs the patient that an enema will be administered before the diagnostic test.

The nurse is administering an enema and observes that the patient's abdomen is rigid and the patient has rectal bleeding. What is the initial nursing action in this situation? 1 Do an immediate patient assessment 2 Slow the rate of instillation of the enema 3 Notify the primary health care provider 4 Discontinue the enema administration

4

A student nurse is learning to auscultate the abdomen for bowel sounds. What should the student nurse know about the bowel sounds before starting to auscultate? Select all that apply. A Normal bowel sounds occur every 5-15 seconds. B Normal bowel sounds are irregular, high-pitched, and gurgling. C Hypoactive bowel sounds are slow and sluggish, with occurrence of fewer than five sounds per minute. D Hyperactive sounds may occur in small intestine obstructions. E Increased bowel sounds are common after surgery.

A, B, and C

Which foods may alter the results of a patient's fecal occult blood test? Select all that apply. A Carrots B Cereals C Red meat D Grapefruit E Milk products

A, C, and D

The nurse is caring for a patient with belching and flatulence. Which instructions does the nurse give the patient to relieve discomfort and pain? Select all that apply. A "Do not rock back and forth." B "Walk on a regular basis." C "Include more cabbage in your diet." D "Stay away from onions." E "Avoid carbonated drinks."

B, D, and E

The nurse is educating a patient about ways to promote bowel motility. What should the nurse include in the teaching? Select all that apply. A "Refrain from eating grapefruit." B "Eliminate cereals from your diet." C "Perform regular aerobic exercises." D "Walk for 10 to 15 minutes per day." E "Exercise immediately after a meal."

C and D