7.10 Ch. 42 Lower GI
608. The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semi-formed stool noted in the ostomy pouch
2 Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.
15. The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.
2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.
16. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.
2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration.
10. Patients with a paralytic ileus typically have: (a) intravenous fluid replacement and a nasogastric tube connected to suction. (b) surgical correction of the problem. (c) endoscopic injection of botulinum toxin or esophageal dilation. (d) endoscopy to allow biopsy followed with broad-spectrum antibiotics.
a
21. The patient is receiving the following medications. Which one is prescribed to relieve symptoms rather than treat a disease? a. Corticosteroids b. 6-Mercaptopurine c. Antidiarrheal agents d. Sulfasalazine (Azulfidine)
c. Antidiarrheal agents only relieve symptoms. Corticosteroids, 6-mercaptopurine, and sulfasalazine (Azulfidine) are used to treat and control inflammation with various diseases.
47. A 60-year-old African American patient is afraid she might have anal cancer. What assessment finding puts her at high risk for anal cancer? a. Alcohol use b. Only one sexual partner c. Human papillomavirus (HPV) d. Use of a condom with sexual intercourse
c. Human papillomavirus (HPV) is associated with about 80% of anal cancer cases. Other risk factors include multiple sexual partners, smoking, receptive anal sex, and HIV infection, as well as being female, age 60, and African American. The other options are not considered risk factors for anal cancer.
15. The patient has peritonitis, which is a major complication of appendicitis. What treatment will the nurse plan to include? a. Peritoneal lavage b. Peritoneal dialysis c. IV fluid replacement d. Increased oral fluid intake
c. IV fluid replacement along with antibiotics, NG suction, analgesics, and surgery would be expected. Peritoneal lavage may be used to determine abdominal trauma. Peritoneal dialysis would not be performed. Oral fluids would be avoided with peritonitis.
17. What laboratory findings are expected in ulcerative colitis as a result of diarrhea and vomiting? a. Increased albumin b. Elevated white blood cells (WBCs) c. Decreased Na+, K+, Mg+, Cl-, and HCO3- d. Decreased hemoglobin (Hgb) and hematocrit (Hct)
c. In the patient with ulcerative colitis, decreased Na+, K+, Mg+, Cl-, and HCO3- are a result of diarrhea and vomiting. Hypoalbuminemia may be present. Elevated WBCs occur with toxic megacolon. Decreased hemoglobin (Hgb) and hematocrit (Hct) occur with bloody diarrhea.
58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.
1, 2, 4 1. A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. 2. Increased fluids will help keep the stool soft and prevent constipation. 3. This will not do anything to help prevent diverticulitis. 4. Exercise will help prevent constipation. 5. No medications are prescribed to prevent an acute exacerbation of diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach.
48. The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms? 1. Instruct the client to avoid drinking fluids with meals. 2. Explain the need to decrease intake of flatus-forming foods. 3. Teach the client how to perform gentle perianal care. 4. Encourage the client to attend a support group meeting.
1. Avoidance of fluids during meals will help prevent abdominal distention, which causes symptoms of IBS. Do not confuse inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS).
37. The nurse working in a skilled nursing facility is collaborating with the dietitian concerning the meals of an immobile client. Which foods are most appropriate for this client? 1. Oatmeal and wheat toast. 2. Cream of wheat and biscuits. 3. Cottage cheese and canned peaches. 4. Tuna on a croissant and applesauce.
1. Oatmeal and wheat toast are high-fiber foods and are recommended for clients who are immobile to help prevent constipation.
115. The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is taped to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.
1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates the bulb is full and needs to be emptied and suction reapplied.
116. The post-anesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.
2. A client who had abdominal surgery usually has a nasogastric (N/G) tube in place. If the N/G tube is not patent, this will cause nausea. Irrigating the N/G tube may relieve nausea.
111. The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.
2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance.
46. The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed? 1. "I should increase fruits, bran, and fluids in my diet." 2. "I will use warm compresses and take sitz baths daily." 3. "I must take a laxative every night and have a stool daily." 4. "I can use an analgesic ointment or suppository for pain."
3. Laxatives can be harsh to the bowel and are habit forming; they should not be taken daily. Stool softeners soften stool and can be taken daily.
14. The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160.
3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.
5. On assessment of the abdomen in a patient with peritonitis, you would expect to find: (a) a soft abdomen with bowel sounds every 2 to 3 seconds. (b) rebound tenderness and guarding. (c) hyperactive, high-pitched bowel sounds and a firm abdomen. (d) ascites and increased vascular pattern on the skin.
b
32. On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find? a. Hyperactive, high-pitched bowel sounds b. A brick-red, puffy stoma that oozes blood c. A purplish stoma, shiny and moist with mucus d. A small amount of liquid fecal drainage from the stoma
b. A normal new colostomy stoma should appear bright red, have mild to moderate edema, and have a small amount of bleeding or oozing of blood when touched. A purplish stoma indicates inadequate blood supply and should be reported. The colostomy will not have any fecal drainage for 2 to 4 days but there may be some earlier mucus or serosanguineous drainage. Bowel sounds after extensive bowel surgery will be diminished or absent.
12. Priority Decision: When caring for a patient with irritable bowel syndrome (IBS), what is most important for the nurse to do? a. Recognize that IBS is a psychogenic illness that cannot be definitively diagnosed. b. Develop a trusting relationship with the patient to provide support and symptomatic care. c. Teach the patient that a diet high in fiber will relieve the symptoms of both diarrhea and constipation. d. Inform the patient that new medications for IBS are available and effective for treatment of IBS manifested by either diarrhea or constipation.
b. Because there is no definitive treatment for irritable bowel syndrome (IBS) and patients become frustrated and discouraged with uncontrolled symptoms, it is important to develop a trusting relationship that will support the patient as different treatments are implemented and evaluated. Diagnosis of IBS can be established by Rome criteria and by elimination of other problems. Although IBS can be precipitated and aggravated by stress and emotions, it is not a psychogenic illness. High-fiber diets may help but they might also increase the bloating and gas pains of IBS. Medications are available but usually used as a last resort because of side effects.
9. Priority Decision: A patient returns to the surgical unit with a nasogastric (NG) tube to low intermittent suction, IV fluids, and a Jackson-Pratt drain at the surgical site following an exploratory laparotomy and repair of a bowel perforation. Four hours after admission, the patient experiences nausea and vomiting. What is a priority nursing intervention for the patient? a. Assess the abdomen for distention and bowel sounds. b. Inspect the surgical site and drainage in the Jackson-Pratt. c. Check the amount and character of gastric drainage and the patency of the NG tube. d. Administer prescribed prochlorperazine (Compazine) to control the nausea and vomiting.
c. An adequately functioning nasogastric (NG) tube should prevent nausea and vomiting because stomach contents are continuously being removed. The first intervention in this case is to check the amount and character of the recent drainage and check the tube for patency. Decreased or absent bowel sounds are expected after a laparotomy and the Jackson-Pratt drains only fluid from the tissue of the surgical site. Antiemetics may be given if the NG tube is patent because anesthetic agents may cause nausea.
592 A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
1, 3, 4 Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
40. The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.
1, 3, 5 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 2. There are midline and perineal incisions, not flank incisions. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. 5. The client should not sit upright because this causes pressure on the perineum.
57. The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal. 2. Assess the client's bowel sounds. 3. Determine the client's last bowel movement. 4. Insert the N/G tube at least 2 more inches.
1. Green bile contains hydrochloric acid and should be draining from the N/G tube; therefore, the nurse should take no action and document the findings.
31. The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients? 1. Discuss coping skills to assist with adaptation to lifestyle modifications. 2. Teach about drug administration, dosages, and scheduled times. 3. Teach dietary changes necessary to control symptoms. 4. Explain the care of the ileostomy and necessary equipment.
1. The objectives for support groups are to help members cope with chronic diseases and help manage symptom control.
142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.
1. This client may have developed an infection from the undercooked meat. The nurse should obtain a stool specimen for the laboratory to analyze.
24. Which problem is most appropriate for the nurse to identify for the client with diarrhea? 1. Alteration in skin integrity. 2. Chronic pain perception. 3. Fluid volume excess. 4. Ineffective coping.
1. When clients have multiple liquid stools, the rectal area can become irritated. The integrity of the skin can be impaired.
36. The nurse plans teaching for the patient with a colostomy but the patient refuses to look at the nurse or the stoma, stating, "I just can't see myself with this thing." What is the best nursing intervention for this patient? a. Encourage the patient to share concerns and ask questions. b. Refer the patient to a chaplain to help cope with this situation. c. Explain that there is nothing the patient can do about it and must take care of it. d. Tell the patient that learning about it will prevent stool leaking and the sounds of flatus.
a. Encouraging the patient to share concerns and ask questions will help the patient to begin to adapt to living with the colostomy. The other options do not support the patient and do not portray the nurse's focus on helping the patient or treating the patient as an individual.
39. An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care? a. Monitor for signs of peritonitis. b. Treat with daily medicated enemas. c. Prepare for surgery to resect the involved colon. d. Provide a heating pad to apply to the left lower quadrant.
a. The inflammation and infection of diverticula cause small perforations with spread of the inflammation to the surrounding area in the intestines. Abscesses may form or complete perforation with peritonitis may occur. Systemic antibiotic therapy is often used but medicated enemas would increase intestinal motility and increase the possibility of perforation, as would the application of heat. Surgery is only necessary to drain abscesses or to resect an obstructing inflammatory mass.
46. The patient asks the nurse to explain what the physician meant when he said the patient had an anorectal abscess. Which description should the nurse use to explain this to the patient? a. Ulcer in anal wall b. Collection of perianal pus c. Sacrococcygeal hairy tract d. Tunnel leading from the anus or rectum
b. An anorectal abscess is a collection of perianal pus. An ulcer in the anal wall is an anal fissure. Sacrococcygeal hairy tract describes a pilonidal sinus. A tunnel leading from the anus or rectum is an anorectal fistula.
45. Which patient is most likely to be diagnosed with short bowel syndrome? a. History of ulcerative colitis b. Had extensive resection of the ileum c. Diagnosed with irritable bowel syndrome d. Had colectomy performed for cancer of the bowel
b. Short bowel syndrome results from extensive resection of portions of the small bowel and would occur if a patient had an extensive resection of the ileum. The other conditions primarily affect the large colon and result in fewer and less severe symptoms.
22. A patient with ulcerative colitis undergoes the first phase of a total proctocolectomy with ileal pouch and anal anastomosis. On postoperative assessment of the patient, what should the nurse expect to find? a. A rectal tube set to low continuous suction b. A loop ileostomy with a plastic rod to hold it in place c. A colostomy stoma with an NG tube in place to provide pouch irrigations d. A permanent ileostomy stoma in the right lower quadrant of the abdomen
b. The initial procedure for a total proctocolectomy with ileal pouch and anal anastomosis includes a colectomy, rectal mucosectomy, ileal reservoir construction, ileoanal anastomosis, and a temporary ileostomy. A loop ileostomy is the most common temporary ileostomy and it may be held in place with a plastic rod for the first week. A rectal tube to suction is not indicated in any of the surgical procedures for ulcerative colitis. A colostomy is not used and an NG tube would not be used to irrigate the pouch. A permanent ileostomy stoma would be expected following a total proctocolectomy with a permanent ileostomy.
39. The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."
1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon.
136. The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.
1. This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding.
12. Which interventions should the nurse discuss regarding prevention of an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a low-fiber diet. 2. Drink 2,500 mL of water daily. 3. Avoid eating foods with seeds. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.
2, 3, 4 1. A high-fiber diet will prevent constipation, the primary reason for diverticulosis/ diverticulitis. A low-fiber (residue) diet is prescribed for acute diverticulitis. 2. Increased fluids help to keep the stool soft and prevent constipation. 3. It is controversial if seeds cause an exacerbation of diverticulosis, but this is an appropriate intervention to teach until proven otherwise. 4. Exercise helps to prevent constipation, which can cause an exacerbation of diverticulitis. 5. There are no medications used to help prevent an acute exacerbation of diverticulosis/ diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach.
133. The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer an oil retention enema. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.
3. Oil retention enemas will help to soften the feces and evacuate the stool.
11. The nurse identifies the client problem "alteration in gastrointestinal system" for the elderly client. Which statement reflects the most appropriate rationale for this problem? 1. Elderly clients have the ability to chew food more thoroughly with dentures. 2. Elderly clients have an increase in digestive enzymes, which helps with digestion. 3. Elderly clients have an increased need for laxatives because of a decrease in bile. 4. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.
4. When the motility of the gastrointestinal tract decreases, bacteria remain in the gut longer and multiply, which results in diarrhea.
609. A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.
1 Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
603. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. "I should increase the fiber in my diet." 2. "I will need to avoid caffeinated beverages." 3. "I'm going to learn some stress reduction techniques." 4. "I can have exacerbations and remissions with Crohn's disease."
1 Rationale: Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
49. The nurse at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement? 1. Stabilize the knife. 2. Remove the knife gently. 3. Turn the client on the side. 4. Apply pressure to the insertion site.
1. The nurse should not remove any penetrating object in the abdomen; removal could cause further internal damage.
611. The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1. "I need to limit my intake of dietary fiber." 2. "I need to drink plenty, at least 8 to 10 cups daily." 3. "I need to eat regular meals and chew my food well." 4. "I will take the prescribed medications because they will regulate my bowel patterns."
1 Rationale: IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.
587. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the health care provider (HCP). 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
1 Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.
139. The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.
1, 4, 5 1. It is important to keep track of the amounts, color, and other characteristics of body fluids excreted. 2. Skin turgor should be assessed at least every six (6) to eight (8) hours, not daily. 3. Carbonated soft drinks increase flatus in the GI tract, and the increased sugar will act as an osmotic laxative and increase diarrhea. 4. Daily weights are the best method of determining fluid loss and gain. 5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort.1. It is important to keep track of the amounts, color, and other characteristics of body fluids excreted. 2. Skin turgor should be assessed at least every six (6) to eight (8) hours, not daily. 3. Carbonated soft drinks increase flatus in the GI tract, and the increased sugar will act as an osmotic laxative and increase diarrhea. 4. Daily weights are the best method of determining fluid loss and gain. 5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort.
50. The nurse writes the problem "risk for impaired skin integrity" for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client? 1. The client will have intact skin around the stoma. 2. The client will be able to change the ostomy bag. 3. The client will express anxiety about the body changes. 4. The client will maintain fluid balance.
1. Intact skin around the stoma is the most appropriate outcome for the problem of "impaired skin integrity."
144. The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
1. Normal serum sodium levels are 135 to 152 mEq/L, so the client's 128 mEq/L value requires intervention.
43. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles? 1. The nurse repeats the information as indicated by the client's questions. 2. The nurse teaches in one session all the information the client needs. 3. The nurse uses a video so the client can hear the medical terms. 4. The nurse waits until the client asks questions about the surgery.
1. The nurse should realize the client is anxious about the diagnosis of cancer and the impending surgery. Therefore, the nurse should be prepared to repeat information as necessary. The learning principle the nurse needs to consider is "anxiety decreases learning."
47. The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement? 1. Establish rapport with the client to decrease embarrassment of assessing site. 2. Encourage the client to lie in the lithotomy position twice a day. 3. Milk the tube inserted during surgery to allow the passage of flatus. 4. Digitally dilate the rectal sphincter to express old blood.
1. The site of the surgery can cause embarrassment when the nurse assesses the site; therefore, the nurse should establish a positive relationship.
119. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postappendectomy and is being discharged.
2. A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, the nurse should assess this client first.
138. The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.
2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.
1. The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent nosocomial spread to other clients? 1. Wash hands with Betadine for two (2) minutes after giving care. 2. Wear nonsterile gloves when handling GI excretions. 3. Clean the perianal area with soap and water after each stool. 4. Flush the commode twice when disposing of stool.
2. Clean gloves should be worn when providing care to prevent the transfer of the bacteria found in the stool. This will prevent the spread of the bacteria to other clients in the health care facility (nosocomial). But this is not a substitute for good hand hygiene.
44. The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement? 1. Change the infusion rate of the intravenous fluid. 2. Encourage the client to ventilate feelings about body image. 3. Administer opioid narcotic medications for pain management. 4. Assist the client out of bed to sit in the chair twice daily.
2. Encouraging the client to verbalize feelings about body changes assists the client to accept these changes. This is an independent intervention not requiring a health-care provider's order.
134. The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."
2. It is not necessary to have a bowel movement every day to have normal bowel functioning.
38. Which intervention should the nurse implement when administering a potassium supplement? 1. Determine the client's allergies. 2. Ask the client about leg cramps. 3. Monitor the client's blood pressure. 4. Monitor the client's complete blood count.
2. Leg cramps occur when serum potassium levels are too low or too high. If the client has leg cramps, this could indicate an imbalance, which could lead to cardiac dysrhythmias.
26. The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan? 1. Fluid volume deficit. 2. Impaired tissue perfusion. 3. Infection of surgical site. 4. Risk for immunosuppression.
2. The perfusion of the surgical site is compromised as a result of the surgical incision, especially when a graft is used.
137. The charge nurse has just received the shift report. Which client should the nurse see first? 1. The client diagnosed with Crohn's disease who had two (2) semi-formed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.
2. This client has just arrived, so the nurse does not know if the complaint is valid and needs intervention unless assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.
10. The client with a diagnosis of rule-out colon cancer is two (2) hours post-sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse? 1. The client has hyperactive bowel sounds. 2. The client is eating a hamburger the family brought. 3. The client is sleepy and wants to sleep. 4. The client's BP is 96/60 and apical pulse is 108.
4. These are signs/symptoms of hypovolemic shock requiring immediate intervention by the nurse.
606. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/ symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm
3 Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
600. The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises
3 Rationale: In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
6. The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse? 1. The client has 20 bloody stools a day. 2. The client's oral temperature is 99.8˚F. 3. The client's abdomen is hard and rigid. 4. The client complains of urinating when coughing.
3. A hard, rigid abdomen indicates peritonitis, a complication of ulcerative colitis, and warrants immediate intervention.
120. The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "Can you describe the type of pain?" 4. "Have you been experiencing any gas?"
3. An elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain.
32. The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis? 1. Increased appetite and thirst. 2. Elevated hemoglobin. 3. Multiple bloody, liquid stools. 4. Exacerbations unrelated to stress.
3. Clients report as many as 10 to 20 liquid bloody stools in a day.
22. The emergency department nurse is working in a community hospital. During the past two (2) hours, 15 clients have been admitted with Salmonella food poisoning. Which information should the nurse discuss with clients? 1. Explain the incubation period is 48 to 72 hours. 2. Explain the source of this poisoning is contaminated water. 3. Explain sources of contamination are eggs and chicken. 4. Explain the bacterial contaminant came from canned foods.
3. Eggs, poultry, and pet turtles are sources of the Salmonellae bacteria, which cause food poisoning.
23. Which intervention should the nurse include when discussing ways to prevent food poisoning? 1. Wash hands for ten (10) seconds after handling raw meat. 2. Clean all cutting boards between meats and fruits. 3. Maintain food temperatures at 140˚F during extended servings. 4. Explain fruits do not require washing prior to eating or preparing.
3. Foods being served for an extended time should be kept at 140°F because food sitting at less than this temperature allows for bacterial growth.
117. The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2 L/min via nasal cannula.
3. Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.
143. The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.
3. The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.
140. The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN? 1. Assist the UAP to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.
3. The LPN can administer medications such as a laxative.
15. Which information should the nurse teach the client post-barium enema procedure? 1. The client should not eat or drink anything for four (4) hours. 2. The client should remain on bedrest until the sedative wears off. 3. The client should take a mild laxative to help expel the barium. 4. The client will have normal elimination color and pattern.
3. The nurse needs to teach the client to take a mild laxative to help evacuate the barium and return to the client's normal bowel routine. Failure to pass the barium could cause constipation when the barium hardens.
610. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance
4 Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
135. The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? 1. Explain some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.
4. A high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively.
45. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention? 1. Presence of thin pink drainage in the Jackson Pratt. 2. Guarding when the nurse touches the abdomen. 3. Tenderness around the surgical site during palpation. 4. Complaints of chills and feeling feverish.
4. Complaints of chills, sudden onset of fever, tachycardia, nausea, and hiccups are symptoms of peritonitis, which is a life-threatening complication.
25. The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction? 1. Steady, aching pain in one specific area. 2. Sharp back pain radiating to the flank. 3. Sharp pain increases with deep breaths. 4. Intermittent colicky pain near the umbilicus.
4. Intermittent and colicky pain located near the umbilicus is indicative of a small bowel obstruction; lumbar pain is indicative of colon involvement.
33. The client is diagnosed with an acute exacerbation of inflammatory bowel disease (IBD). Which food selection would be the best choice for a meal? 1. Roast beef on wheat bread and a milk shake. 2. Hamburger, french fries, and a Coke. 3. Pepper steak, brown rice, and iced tea. 4. Roasted turkey, instant mashed potatoes, and water.
4. Meats can be eaten if prepared by roasting, baking, or broiling. Vegetables should be cooked, not raw, and skins should be removed. Instant mashed potatoes do not have the skin. A low-residue diet should be eaten.
39. The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)? 1. Administer the polyethylene glycol electrolyte lavage solution. 2. Explain to the client why this morning's breakfast is withheld. 3. Start an intravenous site with 0.9% normal saline fluid. 4. Administer a cleansing enema until the return is clear.
4. The administration of enemas can be delegated to the unlicensed assistive personnel (UAP).
141. The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hr. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.
4. This client needs to be cleaned immediately, the abdomen must be assessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is priority.
7. Which measure should the patient with diverticulitis be taught to integrate into his daily routine at home? A. Eating a diet high in digestible fiber B. Limiting fluid intake C. Using enemas to relieve constipation D. Straining with each bowel movement
A. A diet high in digestible fiber is recommended to increase stool volume, decrease colonic transit time, and reduce intraluminal pressure.
4. In a patient with suspected appendicitis, which of these interventions are appropriate? A. Give I.V. fluids, give the patient nothing by mouth, and apply heat to his abdomen for comfort. B. Give I.V. fluids, give the patient nothing by mouth, and give an enema to clean his bowel before surgery. C. Give I.V. fluids; give the patient nothing by mouth, but give analgesics judiciously; and place him in Fowler's position to reduce pain. D. Give clear liquids only along with heat applied to the abdomen for comfort.
C. Never apply heat to the right lower abdomen or give cathartics or enemas because they may cause the appendix to rupture. Give analgesics judiciously because they may mask symptoms of rupture.
4. A patient presents with abdominal pain that is initially periumbilical but over time moves to the right lower quadrant area. This pain is most likely due to: (a) appendicitis. (b) Crohn's disease. (c) cholecystitis. (d) diverticulitis.
a
1. An inflammatory bowel disorder in which the patient develops abdominal pain, bloody diarrhea, tenesmus and weight loss is (a) Crohn's disease. (b) diverticulitis. (c) ulcerative colitis. (d) appendicitis.
c
6. Treatment of the patient with appendicitis includes: (a) transfusion to replace blood loss. (b) bowel prep for cleansing. (c) surgical removal of appendix. (d) medications to lower pH within the stomach.
c
7. Patients with gastrointestinal bleeding may experience an acute or chronic blood loss. Your patient is experiencing hematochezia. You recognize this as: (a) vomiting of bright red or maroon blood. (b) black, tarry stool. (c) coffee ground emesis. (d) red- or maroon-colored stool rectally.
d
112. The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in reverse Trendelenburg position. 4. Administer intravenous antibiotic STAT.
1. Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing.
103. Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.
1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.
99. The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.
1. Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.
17. The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.
1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely.
13. Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence.
1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.
42. The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.
1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening.
22. The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."
1. The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.
55. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102˚F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.
1. These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.
107. Which nursing interventions should be included in the care plan for the 84-year old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.
2, 4, 5 1. The nurse should assess skin turgor over the sternum in the elderly client because loss of subcutaneous fat associated with aging makes skin turgor assessment on the arms less reliable. 2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea. 3. The nurse should record frequency and characteristics of stool, not sputum, in the client diagnosed with gastroenteritis. 4. Standard Precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.
20. The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."
2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces.
37. The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.
2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon.
105. The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.
2. The UAP can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.
60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.
2. The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining the client NPO and a nasogastric tube.
97. The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.
2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.
44. The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."
2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client's statement indicates the need for further teaching.
54. The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.
2. The nurse should always ask about allergies to medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions.
43. The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.
2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate.
101. The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.
2. Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.
102. Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.
3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.
23. The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.
3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended.
110. The client who had abdominal surgery tells the nurse, "I felt something give way in my stomach." Which intervention should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess the abdominal wound incision. 4. Administer pain medication intravenously.
3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.
113. The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements.
3. Because the signs of peritonitis are elevated temperature and rigid abdomen, a reversal of these signs indicates the client is getting better.
52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.
3. Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation.
59. The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.
3. Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.
100. The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.
3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to lifethreatening cardiac dysrhythmias.
106. Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."
3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.
108. The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
3. Tented skin turgor and dry mucus membranes indicate dehydration, which warrants the nurse assessing this client first.
46. The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.
3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.
19. The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"
3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk.
38. The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.
3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation.
51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bedrest with bathroom privileges.
3. The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO.
18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.
3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output.
48. The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.
3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency.
109. The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 g/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000/mm3.
4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level.
114. The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage client to increase oral fluids. 3. Encourage client to take deep breaths. 4. Maintain a patent nasogastric tube.
4. A paralytic ileus is the absence of peristalsis; therefore, the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously.
47. The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.
4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow.
98. Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.
4. Any discolored food, food from a damaged can or jar, or food from a can or jar not having a tight seal should be destroyed without tasting or touching it.
21. The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.
4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.
104. Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.
4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.
53. The client is two (2) hours post-colonoscopy. Which assessment data warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.
4. Bowel perforation is a potential complication of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse.
50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.
4. The client should have regular bowel movements, preferably daily. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis.
49. The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6˚F. Which intervention should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the chart. 3. Administer an oral antipyretic. 4. Assess the client's abdomen.
4. The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis.
41. The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.
4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.
3. Priority Decision: In instituting a bowel training program for a patient with fecal incontinence, what should the nurse first plan to do? a. Teach the patient to use a perianal pouch. b. Insert a rectal suppository at the same time every morning. c. Place the patient on a bedpan 30 minutes before breakfast. d. Assist the patient to the bathroom at the time of the patient's normal defecation.
The first intervention to establish bowel regularity includes promoting bowel evacuation at a regular time each day, preferably by placing the patient on the bedpan, using a bedside commode, or walking the patient to the bathroom. To take advantage of the gastrocolic reflex, an appropriate time is 30 minutes after the first meal of the day or at the patient's usual individual time. Perianal pouches are used to protect the skin only when regularity cannot be established and evacuation suppositories are also used only if other techniques are not successful.
19. For the patient hospitalized with inflammatory bowel disease (IBD), which treatments would be used to rest the bowel (select all that apply)? a. NPO b. IV fluids c. Bed rest d. Sedatives e. Nasogastric suction f. Parenteral nutrition
a, b, e, f. With an acute exacerbation of inflammatory bowel disease (IBD), to rest the bowel the patient will be NPO, receive IV fluids and parenteral nutrition, and have nasogastric suction. Sedatives would be used to alleviate stress. Enteral nutrition will be used as soon as possible.
16. A 20-year old patient with a history of Crohn's disease comes to the clinic with persistent diarrhea. What are characteristics of Crohn's disease (select all that apply)? a. Weight loss c. Abdominal pain d. Toxic megacolon e. Has segmented distribution f. Involves the entire thickness of the bowel wall
a, c, e, f. Crohn's disease may have severe weight loss, segmented distribution through the entire wall of the bowel, and crampy abdominal pain. Rectal bleeding and toxic megacolon are more often seen with ulcerative colitis.
40. The patient calls the clinic and describes a bump at the site of a previous incision that disappears when he lies down. The nurse suspects that this is which type of hernia (select all that apply)? a. Ventral b. Inguinal c. Femoral d. Reducible e. Incarcerated f. Strangulated
a, d. The ventral or incisional hernia is due to a weakness of the abdominal wall at the site of a previous incision. It is reducible when it returns to the abdominal cavity. Inguinal hernias are at the weak area of the abdominal wall where the spermatic cord in men or the round ligament in women emerges. A femoral hernia is a protrusion through the femoral ring into the femoral canal. Incarcerated hernias do not reduce.
29. When obtaining a nursing history from the patient with colorectal cancer, the nurse should specifically ask the patient about a. dietary intake. b. sports involvement. c. environmental exposure to carcinogens. d. long-term use of nonsteroidal antiinflammatory drugs (NSAIDs).
a. A diet high in red meat and low fruit and vegetable intake is associated with development of colorectal cancer (CRC), as are alcohol intake and smoking. Family and personal history of CRC also increases the risk. Other environmental agents are not known to be related to colorectal cancer. Long-term use of nonsteroidal antiinflammatory drugs (NSAIDs) is associated with reduced CRC risk.
6. Which method is preferred for immediate treatment of an acute episode of constipation? a. An enema b. Increased fluid c. Stool softeners d. Bulk-forming medication
a. Enemas are fast acting and beneficial in the immediate treatment of acute constipation but should be limited in their use. Bulk-forming medication stimulates peristalsis but takes 24 hours to act. Stool softeners have a prolonged action, taking up to 72 hours for an effect, and fluids can help to decrease the incidence of constipation.
23. Priority Decision: A patient with ulcerative colitis has a total proctocolectomy with formation of a terminal ileum stoma. What is the most important nursing intervention for this patient postoperatively? a. Measure the ileostomy output to determine the status of the patient's fluid balance. b. Change the ileostomy appliance every 3 to 4 hours to prevent leakage of drainage onto the skin. c. Emphasize that the ostomy is temporary and the ileum will be reconnected when the large bowel heals. d. Teach the patient about the high-fiber, low-carbohydrate diet required to maintain normal ileostomy drainage.
a. Initial output from a newly formed ileostomy may be as high as 1500 to 2000 mL daily and intake and output must be accurately monitored for fluid and electrolyte imbalance. Ileostomy bags may need to be emptied every 3 to 4 hours but the appliance should not be changed for several days unless there is leakage onto the skin. A terminal ileum stoma is permanent and the entire colon has been removed. A return to a normal, presurgical diet is the goal for the patient with an ileostomy, with restrictions based only on the patient's individual tolerances.
13. Priority Decision: A patient with a gunshot wound to the abdomen complains of increasing abdominal pain several hours after surgery to repair the bowel. What action should the nurse take first? a. Take the patient's vital signs. b. Notify the health care provider. c. Position the patient with the knees flexed. d. Determine the patient's IV intake since the end of surgery.
a. It is likely that the patient could be developing a peritonitis, which could be life-threatening, and assessment of vital signs for hypovolemic shock should be done to report to the health care provider. If an IV line is not in place, it should be inserted and pain may be eased by flexing the knees.
24. A patient with inflammatory bowel disease has a nursing diagnosis of imbalanced nutrition: less than body requirements related to decreased nutritional intake and decreased intestinal absorption. Which assessment data support this nursing diagnosis? a. Pallor and hair loss b. Frequent diarrhea stools c. Anorectal excoriation and pain d. Hypotension and urine output below 30 mL/hr
a. Signs of malnutrition include pallor from anemia, hair loss, bleeding, cracked gingivae, and muscle weakness, which support a nursing diagnosis that identifies impaired nutrition. Diarrhea may contribute to malnutrition but is not a defining characteristic. Anorectal excoriation and pain relate to problems with skin integrity. Hypotension relates to problems with fluid deficit.
10. Priority Decision: A postoperative patient has a nursing diagnosis of pain related to effects of medication and decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient? a. Ambulate the patient more frequently. b. Assess the abdomen for bowel sounds. c. Place the patient in high Fowler's position. d. Withhold opioids because they decrease bowel motility.
a. The abdominal pain and distention that occur from the decreased motility of the bowel should be treated with increased ambulation and frequent position changes to increase peristalsis. If the pain is severe, cholinergic drugs, rectal tubes, or application of heat to the abdomen may be prescribed. Assessment of bowel sounds is not an intervention to relieve the pain and a high Fowler's position is not indicated. Opioids may still be necessary for pain control and motility can be increased by other means.
7. Priority Decision: A patient is admitted to the emergency department with acute abdominal pain. What nursing intervention should the nurse implement first? a. Measurement of vital signs b. Administration of prescribed analgesics c. Assessment of the onset, location, intensity, duration, and character of the pain d. Physical assessment of the abdomen for distention, bowel sounds, and pigmentation changes
a. The patient with an acute abdomen may have significant fluid or blood loss into the abdomen and evaluation of blood pressure (BP) and heart rate (HR) should be the first intervention, followed by assessment of the abdomen and the nature of the pain. Analgesics should be used cautiously until a diagnosis can be determined so that symptoms are not masked.
8. When considering the following causes of acute abdomen, the nurse should know that surgery would be indicated for (select all that apply)? a. pancreatitis b. acute ischemic bowel c. foreign-body perforation e. ruptured ectopic pregnancy d. pelvic inflammatory disease f. ruptured abdominal aneurysm
b, c, e, f. An immediate surgical consult is needed for acute ischemic bowel, foreign-body perforation, ruptured ectopic pregnancy, or ruptured abdominal aneurysm. A diagnostic laparoscopy may be done or a laparotomy may be done to repair a ruptured abdominal aneurysm or remove the appendix. Surgery is not needed for pancreatitis or pelvic inflammatory disease, as these can be diagnosed and treated without surgery.
37. What information should be included when the nurse teaches a patient about colostomy irrigation? a. Infuse 1500 to 2000 mL of warm tap water as irrigation fluid. b. Allow 30 to 45 minutes for the solution and feces to be expelled. c. Insert a firm plastic catheter 3 to 4 inches into the stoma opening. d. Hang the irrigation bag on a hook about 36 inches above the stoma.
b. Following infusion of the fluid into the stoma, the solution and feces will take about 30 to 45 minutes to return and the patient can plan to read or perform other quiet activities during the wait time. Between 500 and 1000 mL of warm tap water should be used. A cone tip on the end of the tubing prevents bowel damage that could occur if a stiff plastic catheter is used. Fluid should be elevated about 18 to 24 inches above the stoma, or to about shoulder level, to prevent too rapid infusion of the solution and cramping.
27. An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to a. offer ice chips to suck PRN. b. provide mouth care every 1 to 2 hours. c. irrigate the tube with normal saline every 8 hours. d. keep the patient supine with the head of the bed elevated 30 degrees.
b. Mouth care should be done frequently for the patient with a small intestinal obstruction who has an NG tube because of vomiting, fecal taste and odor, and mouth breathing. No ice chips are allowed when a patient is NPO because of a bowel obstruction. The NG tube should be checked for patency and irrigated as ordered. The position of the patient should be one of comfort.
42. What is a nursing intervention that is indicated for a male patient following an inguinal herniorrhaphy? a. Applying heat to the inguinal area b. Elevating the scrotum with a scrotal support c. Applying a truss to support the operative site d. Encouraging the patient to cough and deep breathe
b. Scrotal edema is a common and painful complication after an inguinal hernia repair and can be relieved in part by application of ice and elevation of the scrotum with a scrotal support. Heat would increase the edema and the discomfort and a truss is used to keep unrepaired hernias from protruding. Coughing is discouraged postoperatively because it increases intraabdominal pressure and stress on the repair site.
43. How is the most common form of malabsorption syndrome treated? a. Administration of antibiotics b. Avoidance of milk and milk products c. Supplementation with pancreatic enzymes d. Avoidance of gluten found in wheat, barley, oats, and rye
b. The most common type of malabsorption syndrome is lactose intolerance and it is managed by restricting the intake of milk and milk products. Antibiotics are used in cases of bacterial infections that cause malabsorption, pancreatic enzyme supplementation is used for pancreatic insufficiency, and restriction of gluten is necessary for control of adult celiac disease (celiac sprue, gluten-induced enteropathy).
14. The patient has persistent and continuous pain at McBurney's point. The nursing assessment reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the right leg flexed. What should the nursing interventions for this patient include? a. Laxatives to move the constipated bowel b. NPO status in preparation for possible appendectomy c. Parenteral fluids and antibiotic therapy for 6 hours before surgery d. NG tube inserted to decompress the stomach and prevent aspiration
b. The patient's manifestations are characteristic of appendicitis. After laboratory test and CT scan confirmation, the patient will have surgery. Laxatives are not used. The 6 hours of fluids and antibiotics preoperatively would be used only if the appendix was ruptured. The NG tube is more likely to be used with abdominal trauma.
25. A physician just told a patient that she has a volvulus. When the patient asks the nurse what this is, what is the best description for the nurse to give her? a. Bowel folding on itself b. Twisting of bowel on itself c. Emboli of arterial supply to the bowel d. Protrusion of bowel in weak or abnormal opening
b. Volvulus is the bowel twisting on itself. The bowel folding on itself is intussusception. Emboli of arterial blood supply to the bowel is vascular obstruction. Protrusion of bowel in a weak or abnormal opening is a hernia.
41. The patient asks the nurse why she needs to have surgery for a femoral, strangulated hernia. What is the best explanation the nurse can give the patient? a. The surgery will relieve her constipation. b. The abnormal hernia must be replaced into the abdomen. c. The surgery is needed to allow intestinal flow and prevent necrosis. d. The hernia is because the umbilical opening did not close after birth as it should have.
c. A strangulated femoral hernia obstructs intestinal flow and blood supply, thus requiring emergency surgery. The other options are incorrect.
28. During a routine screening colonoscopy on a 56-year-old patient, a rectosigmoidal polyp was identified and removed. The patient asks the nurse if his risk for colon cancer is increased because of the polyp. What is the best response by the nurse? a. "It is very rare for polyps to become malignant but you should continue to have routine colonoscopies." b. "Individuals with polyps have a 100% lifetime risk of developing colorectal cancer and at an earlier age than those without polyps." c. "All polyps are abnormal and should be removed but the risk for cancer depends on the type and if malignant changes are present." d. "All polyps are premalignant and a source of most colon cancer. You will need to have a colonoscopy every 6 months to check for new polyps."
c. Although all polyps are abnormal growths, the most common type of polyp (hyperplastic) is non-neoplastic, as are inflammatory, lipomas, and juvenile polyps. However, adenomatous polyps are characterized by neoplastic changes in the epithelium and most colorectal cancers appear to arise from these polyps. Only patients with a family history of familial adenomatous polyposis (FAP) have close to a 100% lifetime risk of developing colorectal cancer.
1. The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea makes which statement? a. "I can use A&D ointment or Vaseline jelly around the anal area to protect my skin." b. "Gatorade is a good liquid to drink because it replaces the fluid and salts I have lost." c. "I may use over-the-counter Imodium or Parepectolin when I need to control the diarrhea." d. "I must wash my hands after every bowel movement to prevent spreading the diarrhea to my family."
c. Antiperistaltic agents, such as loperamide (Imodium) and paregoric, should not be used in infectious diarrhea because of the potential of prolonging exposure to the infectious agent. Demulcent agents may be used to coat and protect mucous membranes in these cases. The other options are all appropriate measures to use in cases of infectious diarrhea.
20. The medications prescribed for the patient with inflammatory bowel disease include cobalamin and iron injections. What is the rationale for using these drugs? a. Alleviate stress b. Combat infection c. Correct malnutrition d. Improve quality of life
c. Cobalamin and iron injections will help to correct malnutrition. Correcting malnutrition will also indirectly help to improve quality of life and fight infections.
38. What should the nurse teach the patient with diverticulosis to do? a. Use anticholinergic drugs routinely to prevent bowel spasm. b. Have an annual colonoscopy to detect malignant changes in the lesions. c. Maintain a high-fiber diet and use bulk laxatives to increase fecal volume. d. Exclude whole grain breads and cereals from the diet to prevent irritating the bowel.
c. Formation of diverticula is common when decreased bulk of stool, combined with a more narrowed lumen in the sigmoid colon, causes high intraluminal pressures that result in saccular dilation or outpouching of the mucosa through the muscle of the intestinal wall. To prevent the high intraluminal pressure, fecal volume should be increased with use of high-fiber diets and bulk laxatives, such as psyllium (Metamucil). Anticholinergic drugs are used only during an acute episode of diverticulitis and the lesions are not premalignant.
26. The patient comes to the emergency department with intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration. The nurse suspects a GI obstruction. Based on the manifestations, what area of the bowel should the nurse suspect is obstructed? a. Large intestine b. Esophageal sphincter c. Upper small intestine d. Lower small intestine
c. Intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration are characteristics of mechanical upper small intestinal obstruction. With continued vomiting, metabolic alkalosis may occur. Large bowel obstruction is characterized by constipation, low-grade abdominal pain, and abdominal distention. Fecal vomiting is seen with lower small intestinal obstruction.
5. The nurse should teach the patient with chronic constipation that which food has the highest dietary fiber? a. Peach b. Popcorn c. Dried beans d. Shredded wheat
c. Of the foods listed, dried beans contain the highest amount of dietary fiber and are an excellent source of soluble fiber. Bran and berries also have large amounts of fiber.
44. A patient is diagnosed with celiac disease following a workup for iron-deficiency anemia and decreased bone density. The nurse identifies that additional teaching about disease management is needed when the patient makes which statement? a. "I should ask my close relatives to be screened for celiac disease." b. "If I do not follow the gluten-free diet, I might develop a lymphoma." c. "I don't need to restrict gluten intake because I don't have diarrhea or bowel symptoms." d. "It is going to be difficult to follow a gluten-free diet because it is found in so many foods."
c. The autoimmune process associated with celiac disease continues as long as the body is exposed to gluten, regardless of the symptoms it produces, and a lifelong gluten-free diet is necessary. The other statements regarding celiac disease are all true.
2. Priority Decision: What is the most important thing the nurse should do when caring for a patient who has contracted Clostridium difficile? a. Clean the entire room with ammonia. b. Feed the patient yogurt with probiotics. c. Wear gloves and wash hands with soap and water. d. Teach the family to use alcohol-based hand cleaners.
c. Wearing gloves will avoid hand contamination and washing hands with soap and water will remove more Clostridium difficile spores than alcohol-based hand cleaners and ammonia-based disinfectants. The entire room will need to be disinfected with a 10% solution of household bleach. Probiotics may help to prevent diarrhea in the patient on antibiotics by replacing normal intestinal bacteria.
33. Delegation Decision: The RN coordinating the care for a patient who is 2 days postoperative following an anterior-posterior resection with colostomy may delegate which interventions to the licensed practical nurse (LPN) (select all that apply)? a. Irrigate the colostomy. b. Teach ostomy and skin care. c. Assess and document stoma appearance. d. Monitor and record the volume, color, and odor of the drainage. e. Empty the ostomy bag and measure and record the amount of drainage.
d, e. The licensed practical nurse (LPN) can monitor and record observations related to the drainage and can measure and record the amount. The LPN could also monitor the skin around the stoma for breakdown. LPNs can irrigate a colostomy in a stable patient but this patient is only 2 days postoperative. The other actions are responsibilities of the RN (teaching, assessing stoma, and developing a care plan).
4. A nurse is doing a nursing assessment on a patient with chronic constipation. What data obtained during the interview may be a factor contributing to the constipation? a. Taking methylcellulose (Citrucel) daily b. High dietary fiber with high fluid intake c. History of hemorrhoids and hypertension d. Suppressing the urge to defecate while at work
d. Ignoring the urge to defecate causes the muscles and mucosa in the rectal area to become insensitive to the presence of feces and drying of the stool occurs. The urge to defecate is decreased and stool becomes more difficult to expel. Taking a bulk-forming agent with fluids or high fiber diet with fluids prevent constipation. Hemorrhoids are the most common complication of chronic constipation, caused by straining to pass hardened stool. The straining may cause problems in patients with hypertension but these do not cause constipation. Other things that may cause constipation are a history of diverticulosis, which is seen in individuals with low fiber intake, small stool mass, and hard stools. Chronic laxative use and chronic dilation and loss of colonic tone may also cause chronic constipation.
34. A male patient who has undergone an anterior-posterior repair is worried about his sexuality. What is an appropriate nursing intervention for this patient? a. Have the patient's sexual partner reassure the patient that he is still desirable. b. Reassure the patient that sexual function will return when healing is complete. c. Remind the patient that affection can be expressed in ways other than through sexual intercourse. d. Explain that physical and emotional factors can affect sexual function but not necessarily the patient's sexuality.
d. Sexual dysfunction may result from an anterior-posterior repair but the nurse should discuss with the patient that different nerve pathways affect erection, ejaculation, and orgasm and that a dysfunction of one does not mean total sexual dysfunction and also that an alteration in sexual activity does not have to alter sexuality. Simple reassurance of desirability and ignoring concerns about sexual function do not help the patient to regain positive feelings of sexuality.
31. The patient with a new ileostomy needs discharge teaching. What should the nurse plan to include in this teaching? a. The pouch can be worn for up to 2 weeks before changing it. b. Decrease the amount of fluid intake to decrease the amount of drainage. c. The pouch can be removed when bowel movements have been regulated. d. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch.
d. The ileostomy drainage is extremely irritating to the skin, so the skin must be cleaned and a new solid skin barrier and pouch applied as soon as a leak occurs to prevent skin damage. The pouch is usually worn for 4 to 7 days unless there is a leak. Because the initial drainage from the ileostomy is high, the fluid intake must not be decreased. The pouch must always be worn, as the liquid drainage, not formed bowel movements, is frequent.
11. A 22-year-old patient calls the outpatient clinic complaining of nausea and vomiting and right lower abdominal pain. What should the nurse advise the patient to do? a. Use a heating pad to relax the muscles at the site of the pain. b. Drink at least 2 quarts of juice to replace the fluid lost in vomiting. c. Take a laxative to empty the bowel before examination at the clinic. d. Have the symptoms evaluated by a health care provider right away.
d. The patient is having symptoms of an acute abdomen and should be evaluated by a health care provider immediately. The patient's age, location of pain, and other symptoms are characteristic of appendicitis. Heat application and laxatives should not be used in patients with undiagnosed abdominal pain because they may cause perforation of the appendix or other inflammations. Fluids should not be taken until vomiting is controlled, nor should they be taken in the event that surgery may be performed.
35. In report, the nurse learns that the patient has a transverse colostomy. What should the nurse expect when providing care for this patient? a. Semiliquid stools with increased fluid requirements b. Liquid stools in a pouch and increased fluid requirements c. Formed stools with a pouch, needing irrigation, but no fluid needs d. Semiformed stools in a pouch with the need to monitor fluid balance
d. The patient with a transverse colostomy has semiliquid to semiformed stools needing a pouch and needs to have fluid balance monitored. The ascending colostomy has semiliquid stools needing a pouch and increased fluid. The ileostomy has liquid to semiliquid stools needing a pouch and increased fluid. The sigmoid colostomy has formed stools and may or may not need a pouch but will need irrigation.
18. What extraintestinal manifestations are seen in both ulcerative colitis and Crohn's disease? a. Celiac disease and gallstones b. Peptic ulcer disease and uveitis c. Conjunctivitis and colonic dilation d. Erythema nodosum and osteoporosis
d. Ulcerative colitis and Crohn's disease have many of the same extraintestinal symptoms, including erythema nodosum and osteoporosis, as well as gallstones, uveitis, and conjunctivitis. Colonic dilation and celiac disease are not extraintestinal.
48. Following a hemorrhoidectomy, what should the nurse advise the patient to do? a. Use daily laxatives to facilitate bowel emptying. b. Use ice packs to the perineum to prevent swelling. c. Avoid having a bowel movement for several days until healing occurs. d. Take warm sitz baths several times a day to promote comfort and cleaning.
d. Warm sitz baths provide comfort, healing, and cleansing of the area following all anorectal surgery and may be done three or four times a day for 1 to 2 weeks. Stool softeners may be prescribed for several days postoperatively to help keep stools soft for passage but laxatives may cause irritation and trauma to the anorectal area and are not used postoperatively. Early passage of a bowel movement, although painful, is encouraged to prevent drying and hardening of stool, which would result in an even more painful bowel movement.
30. When a patient returns to the clinical unit after an abdominal-perineal resection (APR), what should the nurse expect? a. An abdominal dressing b. An abdominal wound and drains c. A temporary colostomy and drains d. A perineal wound, drains, and a stoma
d. With an abdominal perineal-resection (APR), an abdominal incision is made and the proximal sigmoid colon is brought through the abdominal wall and formed into a permanent colostomy. The patient is repositioned, a perineal incision is made, and the distal sigmoid colon, rectum, and anus are removed through the perineal incision, which may be left open, packed, and have drains.
