Practice Questions PT 2: Lower GI problems

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When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching? "I will be able to regulate when I have stools." "I will be able to wear the pouch until it leaks." "The drainage from my stoma can damage my skin." "Dried fruit and popcorn must be chewed very well."

"I will be able to regulate when I have stools." An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse? "It will increase bulk in the stool." "It will lubricate the intestinal tract to soften feces." "It will increase fluid retention in the intestinal tract." "It will increase peristalsis by stimulating nerves in the colon wall."

"It will increase peristalsis by stimulating nerves in the colon wall." Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. Fiber and bulk- forming drugs increase bulk in the stool. Water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate? "It will reduce the amount of acid in the stomach." "It will prevent air from accumulating in the stomach, causing gas pains." "It will prevent the heartburn that occurs as a side effect of general anesthesia." "The stress of surgery is likely to cause stomach bleeding if you do not receive it."

"It will reduce the amount of acid in the stomach." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

• Treatment of appendicitis is

immediate surgical removal.

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? "The tube will help to drain the stomach contents and prevent further vomiting." "The tube will push past the area that is blocked and thus help to stop the vomiting." "The tube is just a standard procedure before many types of surgery to the abdomen." "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

"The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

• The overall goals are that the patient with diarrhea will have

(1) no transmission of the microorganism causing the infectious diarrhea, (2) cessation of diarrhea and resumption of normal bowel patterns, (3) normal fluid and electrolyte and acid-base balance, (4) normal nutritional status, and (5) no perianal skin breakdown.

• Symptoms of lactase deficiency include

, flatulence, cramping abdominal pain, and diarrhea, which usually occur within a half hour to several hours after drinking a glass of milk or ingesting a milk product.

• The two major aspects of nursing care for the patient undergoing ostomy surgery are

1 Emotional support. 2. Caring for the ostomy

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the change. The available syrup contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer._______________ mL

10 The concentration of the syrup is 10 mg/mL (150 mg÷15 mL=10 mg/mL). Therefore, a 100-mg dose necessitates 10 mL (100 mg÷10 mg/mL=10 mL).

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse? 2 to 5 minutes 15 to 60 minutes 2 to 4 hours 6 to 8 hours

15 to 60 minutes Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 7:00 AM, 10:00 AM, and 1:00 PM 8:00 AM, 12:00 PM, and 4:00 PM 9:00 AM and 3:00 PM 9:00 AM, 12:00 PM, and 3:00 PM

8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

• Crohn's disease and ulcerative colitis are

immunologically related disorders that are referred to as "inflammatory bowel disease" (IBD).

The nurse identifies that which patient is at highest risk for developing colon cancer? A 28-yr-old man who has a body mass index of 27 kg/m2 A 32-yr-old woman with a 12-year history of ulcerative colitis A 52-yr-old man who has followed a vegetarian diet for 24 years A 58-yr-old woman taking prescribed estrogen replacement therapy

A 32-yr-old woman with a 12-year history of ulcerative colitis Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity (body mass index ?5= 30 kg/m2); family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer syndrome; eating red meat (?5=7 servings/week); cigarette use; and drinking alcohol (?5=4 drinks/week).

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible. DIF: Cognitive Level: Apply (application) REF: 959 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

• Malabsorption results from

impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins.

A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? A nursing assistant on the unit who also has hospice experience A licensed practical nurse that has worked on the unit for 10 years A registered nurse with 6 months of experience on the surgical unit A registered nurse who has floated to the surgical unit from pediatrics

A registered nurse with 6 months of experience on the surgical unit The patient needs ostomy care directions and reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat. DIF: Cognitive Level: Analyze (analysis) REF: 964 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. prepare for colonoscopy. c. give stool softeners and enemas. d. order a diet high in fiber and fluids.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis. DIF: Cognitive Level: Apply (application) REF: 964 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL. DIF: Cognitive Level: Understand (comprehension) REF: 958 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turner's sign.

ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis. DIF: Cognitive Level: Understand (comprehension) REF: 941 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which prescribed intervention for a patient with chronic short bowel syndrome will the nurse question? a. Senna 1 tablet every day b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: A Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time. DIF: Cognitive Level: Apply (application) REF: 936 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 970 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort. DIF: Cognitive Level: Apply (application) REF: 944 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Many over-the-counter (OTC) medications can cause constipation. b. Stimulant and saline laxatives can be used regularly. c. Bulk-forming laxatives are an excellent source of fiber. d. Walking or cycling frequently will help bowel motility. e. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

• Prevention and treatment of fecal incontinence may be managed by

implementing a bowel training program.

• Ulcerative colitis usually starts

in the rectum and moves in a continual fashion toward the cecum.

• Lactase deficiency is a condition

in which the lactase enzyme is deficient or absent.

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea. DIF: Cognitive Level: Analyze (analysis) REF: 968 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

The nurse preparing for the annual physical exam of a 50-yr-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50 years, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50 years. DIF: Cognitive Level: Apply (application) REF: 954 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated. DIF: Cognitive Level: Analyze (analysis) REF: 947 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention. DIF: Cognitive Level: Analyze (analysis) REF: 955 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

• Common injuries of the abdomen include

include lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestine rupture.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy. DIF: Cognitive Level: Analyze (analysis) REF: 959 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Develop a detailed written list of ostomy care tasks for the patient. d. Postpone any teaching until the patient adjusts to the ileostomy.

A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse. DIF: Cognitive Level: Apply (application) REF: 963 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom. DIF: Cognitive Level: Apply (application) REF: 934 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

• The overall goals are that the patient with constipation will

increase dietary intake of fiber and fluids; increase physical activity; have the passage of soft, formed stools; and not have any complications, such as bleeding hemorrhoids.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. DIF: Cognitive Level: Apply (application) REF: 962 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which information will the nurse teach a patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose. DIF: Cognitive Level: Understand (comprehension) REF: 949 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which information will the nurse teach a 23-year-old patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is a better choice than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems. DIF: Cognitive Level: Analyze (analysis) REF: 952 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

A new 19-yr-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient. DIF: Cognitive Level: Apply (application) REF: 953 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? a. Ferrous sulfate (Feosol) 325 mg daily b. Senna (Senokot) 1 tablet every day c. Psyllium (Metamucil) 2.1 grams 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: B Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea."

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed. DIF: Cognitive Level: Apply (application) REF: 947 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

• Major risk factors of colorectal cancer (CRC) include

increasing age, family or personal history of colorectal cancer (CRC), colorectal polyps, and IBD.

• All cases of acute diarrhea should be considered

infectious until the cause is known. Strict infection control precautions are necessary.

A 25-yr-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 932 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

Diverticulitis is

inflammation of the diverticula, resulting in complications such as perforation, abscess, fistula formation, and bleeding.

The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: B The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

A 74-yr-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 933 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• Types of hernias include

inguinal, femoral, and ventral or incisional. Diagnosis is based on the history and physical examination relative to the type of hernia.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.

ANS: B Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool. DIF: Cognitive Level: Apply (application) REF: 950 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.

ANS: B, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation. DIF: Cognitive Level: Understand (comprehension) REF: 935 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

• IBS is a chronic functional disorder characterized by

intermittent and recurrent abdominal pain and stool pattern irregularities (diarrhea, constipation, or both).

The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? a. Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. b. The patient will begin sitting in a chair at the bedside on the first postoperative day. c. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.

ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. DIF: Cognitive Level: Analyze (analysis) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

• Common causes of chronic abdominal pain include

irritable bowel syndrome (IBS), diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflammatory disease, and vascular insufficiency.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile. DIF: Cognitive Level: Apply (application) REF: 932 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. DIF: Cognitive Level: Analyze (analysis) REF: 956 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean. DIF: Cognitive Level: Apply (application) REF: 969 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

• Celiac disease is treated with

lifelong avoidance of dietary gluten. Wheat, barley, oats, and rye products must be avoided.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs. DIF: Cognitive Level: Apply (application) REF: 960 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 949 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. check for tube placement and reposition it. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded. DIF: Cognitive Level: Analyze (analysis) REF: 939 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions. DIF: Cognitive Level: Analyze (analysis) REF: 933 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment. DIF: Cognitive Level: Apply (application) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

• The causes of intestinal obstruction can be classified as

mechanical or nonmechanical and can be partial or complete.

• IBD is characterized by

mild to severe acute exacerbations that occur at unpredictable intervals over many years.

A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

ANS: C The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time. DIF: Cognitive Level: Apply (application) REF: 942 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment. DIF: Cognitive Level: Analyze (analysis) REF: 948 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Draw a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan.

ANS: C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. DIF: Cognitive Level: Analyze (analysis) REF: 939 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. DIF: Cognitive Level: Apply (application) REF: 960 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will begin sitting in a chair at the bedside on the first postoperative day. b. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. c. An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

ANS: D A WOCN should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria. DIF: Cognitive Level: Apply (application) REF: 960 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain. DIF: Cognitive Level: Apply (application) REF: 965 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• Blunt trauma commonly occurs with

motor vehicle accidents and falls, and may not be obvious because it does not leave an open wound.

A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

A patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction. DIF: Cognitive Level: Apply (application) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk b. wheat toast with butter c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do. DIF: Cognitive Level: Apply (application) REF: 967 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. iron dextran infusions b. oral ferrous sulfate tablets. c. routine blood transfusions. d. cobalamin (B12) supplements.

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. DIF: Cognitive Level: Apply (application) REF: 946 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria. DIF: Cognitive Level: Apply (application) REF: 940 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

• Clinical manifestations of Gastroenteritis include

nausea, vomiting, diarrhea, abdominal cramping, and distention. Most cases are self-limiting and do not require hospitalization.

• Pain is the most common symptom of a problem. There may also be

nausea, vomiting, diarrhea, fatigue, fever, and constipation.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 60-yr-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool c. A 40-yr-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses. DIF: Cognitive Level: Analyze (analysis) REF: 938 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about hand-washing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented. DIF: Cognitive Level: Analyze (analysis) REF: 932 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.

ANS: D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. DIF: Cognitive Level: Apply (application) REF: 960 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

• Adenomatous polyps are characterized by

neoplastic changes in the epithelium and are closely linked to colorectal adenocarcinoma.

A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? Instruction on irrigating a colostomy Administration of a cleansing enema A high-fiber diet the day before surgery Administration of IV antibiotics for bowel preparation

Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room. A clear liquid diet will be used the day before surgery with the bowel cleansing.

• The goals for the patient with CRC include

normal bowel elimination patterns, quality of life appropriate to disease progression, relief of pain, and feelings of comfort and well-being.

On examining a patient suspected of having appendicitis, what characteristics of the ailment is the nurse likely to find? Select all that apply. 1 Muscle guarding 2 High-grade fever 3 Pain at McBurney's point 4 Pain decreased by coughing 5 Patient prefers to lie still, with his right leg flexed.

Appendicitis is usually manifested by muscle guarding, localized tenderness, and rebound tenderness. The patient may have pain over the McBurney's point, which is the area halfway between the umbilicus and the right iliac crest. The patient may prefer to lie still, with the right leg flexed. Fever may or may not be present; if present, then usually it is a low-grade fever. The pain increases during activities like coughing, sneezing, and deep breathing. Text Reference - p. 974 1,3,5

Lifestyle factors associated with CRC include

obesity, smoking, alcohol, and a large intake of processed and/or red meat.

• Fecal incontinence, the involuntary passage of stool

occurs when the normal structures that maintain continence are disrupted.

• Treatment for chronic abdominal pain is comprehensive and directed toward

palliation of symptoms using nonopioid analgesics and antiemetics, as well as psychologic or behavioral therapies.

• Appendicitis typically begins with

periumbilical pain, followed by anorexia, nausea, and vomiting.

• The pain of appendicitis is

persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney's point.

• A hernia is a

protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in which it is normally contained.

Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)? Restricted to rectum Strictures are common Bloody, diarrhea stools Cramping abdominal pain Lesions penetrate intestine

Bloody, diarrhea stools Cramping abdominal pain Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

* Treatment of IBS is directed at

psychologic and dietary factors as well as medications to regulate output.

The nurse is reviewing various food choices for a patient who has been newly diagnosed with celiac disease. Which food choices are appropriate selections for this patient? Select all that apply. 1 Salsa and corn chips 2 Beef and barley soup 3 Yogurt with fresh fruit 4 Bagels with cream cheese 5 Scrambled eggs and sausage

Celiac disease is treated with lifelong avoidance of dietary gluten. Salsa and corn chips, yogurt with fresh fruit, and scrambled eggs and sausage would be appropriate choices for the patient with celiac disease. Wheat, barley, oats, and rye products must be avoided. Although pure oats do not contain gluten, oat products can become contaminated with wheat, rye, and barley during the milling process. Gluten also is found in pizza, pasta, and bagels. Gluten also is found in some medications and in many food additives, preservatives, and stabilizers. 1,3,5

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? Write an incident report about this untoward event. Attempt to have the family convince the patient to take the ordered dose. Withhold the medication at this time and try to administer it later in the day. Chart the dose as not given on the medical record and explain in the nursing progress notes.

Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

• Patients receiving antibiotics are susceptible to

Clostridium difficile (C. difficile), which is a serious bacterial infection.

A patient who has a family history of colon cancer asks the nurse about tests for colon cancer. Which of these is considered the best method for colorectal cancer (CRC) screening? 1 Colonoscopy 2 Barium enema 3 Sigmoidoscopy 4 Fecal occult blood test (FOBT)

Colonoscopy is the gold standard for CRC screening because the entire colon is examined (only 50% of CRCs are detected by sigmoidoscopy), biopsies can be obtained, and polyps can be removed immediately and sent to the laboratory for examination. Less favorable, but acceptable, screening methods include testing the stool for fecal blood. The FOBT and fecal immunochemical test (FIT) look for blood in the stool. Stool tests must be done frequently, because tumor bleeding occurs at intervals and easily may be missed if a single test is done. Text Reference - p. 987 1

• Expected outcomes for the patient with acute abdominal pain include

resolution of the cause of the acute abdominal pain; relief of abdominal pain; freedom from complications (especially hypovolemic shock and septicemia); and normal fluid, electrolyte, and nutritional status.

The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? Ask family members whether they have discussed the surgical procedure with the physician. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. Delay the patient's signature on the consent and notify the physician about the conversation with the patient

Delay the patient's signature on the consent and notify the physician about the conversation with the patient The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

A nurse teaching a community group about ways to reduce the risk for colorectal cancer includes decreasing the dietary intake of: 1 Beef and pork 2 Fish and poultry 3 Fresh and dried fruits 4 Green leafy vegetables

Development of colorectal cancer has been associated with consumption of a high-fat diet. Of the foods listed, beef and pork are the highest in fat content. A diet that includes plenty of fresh fruits, vegetables, fish, and poultry is best for reduce the risk of colorectal and other forms of cancer. 1

• The goals of treatment for IBD include the following:

rest the bowel, control the inflammation, combat infection, correct malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action? Wear a mask to prevent transmission of infection. Wipe equipment with ammonia-based disinfectant. Instruct visitors to use the alcohol-based hand sanitizer. Don gloves and gown before entering the patient's room.

Don gloves and gown before entering the patient's room. Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room, and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

A patient has a newly formed ileostomy and asks the nurse, "When can I start training my ostomy to only produce stool at certain times?" What is the nurse's appropriate response? 1 "We will start training when the stoma heals." 2 "When your stools transition from liquid to semisolid." 3 "Because you have an ileostomy and not a colostomy, we can start any time." 4 "We will not be able to train your ileostomy because of the frequent drainage from the site."

Drainage from the ileostomy is frequent, of liquid consistency, and irritating to the skin, preventing regularity from being established. Not all colostomies can be trained. A colostomy formed in the sigmoid or descending colon produces semiformed or formed stools and can be regulated by the irrigation method. Text Reference - p. 992 4

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes Oranges, baked potatoes, and raw carrots Dried beans, All Bran (100%) cereal, and raspberries

Dried beans, All Bran (100%) cereal, and raspberries A high-fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

The patient asks the nurse how bisacodyl (Dulcolax) exerts its effects. Which reply by the nurse is most appropriate? 1 "It increases the water content of stool in the gastrointestinal tract, leading to softer bowel movements." 2 "It directly stimulates the smooth muscle in the bowel." 3 "It prevents water in the stool from being absorbed into the bloodstream." 4 "It contains oil to speed up the passage of stool through the intestine."

Dulcolax has a stimulant effect on the colon, increasing peristalsis, leading to soft but formed stools within 12 hours. Water content of the stool is not affected and there is no oil in the medication to lubricate the stool. 2

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate? Return the patient to NPO status. Incorrect Place cool compresses on the abdomen. Encourage the patient to ambulate as ordered. Administer an as-needed dose of IV morphine sulfate

Encourage the patient to ambulate as ordered. Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide, which stimulates peristalsis. A heating pad can help to alleviate some of the pain and help make the patient more comfortable. There is no need for the patient to return to NPO status. Drinking ginger ale may be helpful.

A 28-year-old woman calls the office nurse and states, "I am having the worst abdominal pain! It just started this afternoon. Is there anything I can take to get relief?" Which answer by the nurse is appropriate? 1 "Try taking a laxative and let us know how that works." 2 "You could try an enema to see if that brings quick relief." 3 "Take some aspirin or acetaminophen and let us know if the pain is not relieved." 4 "Please have someone bring you to the office today so that we can do an examination."

Encourage the patient with abdominal pain to see a health care provider and to avoid self-treatment. Laxatives and enemas are especially dangerous because the resulting increased peristalsis may cause perforation of an inflamed appendix. Taking pain medication is not an appropriate action for abdominal pain of unknown origin. Text Reference - p. 969 4

A patient has an inguinal hernia. The patient asks the nurse to explain the diagnosis. How should the nurse respond? 1 Tell the patient not to worry because hernias are common 2 Refer the patient to the primary health care provider for additional information 3 Explain that a hernia is often the result of prenatal growth abnormalities that appear later in life 4 Explain that a hernia is a loop of bowel protruding through a weak spot in the muscles of the abdomen

Explaining that a hernia is a loop of bowel protruding through a weak spot in the muscles of the abdomen is the correct explanation to give the patient. Once the nurse explains to the patient about inguinal hernia, the patient should be referred to his primary healthcare provider for additional consultation. Telling the patient not to worry and offering inaccurate explanations are inappropriate responses by the nurse. Text Reference - p. 996 4

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse? Fecal impaction Perineal hygiene Dietary fiber intake Antidiarrheal agent use

Fecal impaction Patients with limited mobility are at risk for fecal impactions caused by constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

• With Crohn's disease, diarrhea and __

__colicky abdominal pain are common symptoms. If the small intestine is involved, weight loss and nutritional problems are common because of malabsorption. Patients may have systemic symptoms such as fever.

• Bowel surgery can__

__disrupt nerve and vascular supply to the genitals. Radiation therapy, chemotherapy, and medications can also alter sexual function.

A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? Nausea and vomiting Hyperactive bowel sounds Firmly distended abdomen Abrasions on all extremities

Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

In planning the care of a patient newly diagnosed with celiac disease, what aspects of care should be included? Select all that apply. 1 Dietary management 2 Family screening 3 Monitoring of serum folate, iron, and coalamin levels 4 Bone density and osteoporosis screenings 5 Decrease in activity level 6 Need for additional immunizations

Genetic predisposition and gluten ingestion are factors involved in the development of celiac disease. As a result, dietary management and family screening is required. Absorption of nutrients is impaired because of the inflammation in the small intestine, causing alterations in serum folate, iron, coalamin, calcium, and vitamin D levels. There is not a need for additional immunizations and a decrease in activity level is not recommended. Text Reference - p. 997 1,2,3,4

A patient informs the nurse that he or she has been constipated and straining with defecation. When the perineum was cleaned after defecating, the patient noticed blood on the toilet tissue. What does the nurse immediately suspect as the source of bleeding? 1 Anal fissure 2 Hemorrhoids 3 Anorectal abscess 4 Anal fistula

Hemorrhoids are the most common reason for bleeding with defecation. Although bleeding can be associated with an anal fissure and anal fistula, it is not the most common cause of bleeding with defecation. An anorectal abscess is less commonly associated with bleeding upon defecation. 2

The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? Low-pitched and rumbling above the area of obstruction High-pitched and hypoactive below the area of obstruction Incorrect Low-pitched and hyperactive below the area of obstruction High-pitched and hyperactive above the area of obstruction

High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer? Osteoarthritis History of colorectal polyps History of lactose intolerance Use of herbs as dietary supplements

History of colorectal polyps

• Surgery is the treatment of choice __

__for hernias and prevents strangulation.

• Clinical manifestations are usually __

__nonspecific and differ by the location of the lesion within the colon. Most report hematochezia, melena, abdominal pain, and/or changes in bowel habits.

History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy? How to care for the wound How to deep breathe and cough The location and care of drains after surgery Which medications will be used during surgery

How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event? Impaired peristalsis Irritation of the bowel Nasogastric suctioning Inflammation of the incision site

Impaired peristalsis Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility, leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

The cause of diverticulitis is unknown:__

__the majority of patients with diverticular disease are asymptomatic. Those with symptoms typically have abdominal pain, bloating, flatulence, and/or changes in bowel habits.

Although there is sometimes mild inflammation in the terminal ileum__

__ulcerative colitis is a disease of the colon and rectum.

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)? Initiate contact isolation precautions. Place the patient on a clear liquid diet. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Use hand sanitizer before and after patient or bodily fluid contact.

Initiate contact isolation precautions. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Initiation of contact isolation precautions must be done immediately with a patient with C. difficile, which includes washing hands with soap and water before and after patient or bodily fluid contact. Alcohol-based sanitizers are ineffective. Visitors need to be taught to wear gloves and gowns and wash hands. A clear liquid diet is not necessary. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy.

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which is the highest priority nursing intervention that should be included in the patient's plan of care? 1 Initiate the contact isolation precautions 2 Teach visitors to wear gloves and gowns 3 Provide live yogurt cultures for snacking 4 Disinfect the room with 10% bleach solution

Initiation of contact isolation precautions must be done immediately with a patient with C. difficile. Visitors need to be taught to wear gloves and gowns and wash hands as soon as the isolation supplies are at the patient's room, but it's not the highest priority. Eating live yogurt cultures for snacks may not help the patient, but it will not hurt the patient, although it is not the highest priority. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy, but it is not the highest priority. 1

The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question? Bisacodyl Lubiprostone Cascara sagrada Magnesium hydroxide

Magnesium hydroxide Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet. Discontinue intake of medications causing constipation. Eat several small meals per day to maintain bowel motility. Sit upright during meals to increase bowel motility by gravity

Maintain a high intake of fluid and fiber in the diet. Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be discontinued. Eating several small meals per day and position do not facilitate bowel motility.

he nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record? Abdominal pain and bloating No bowel movement for 3 days A decrease in appetite by 50% over 24 hours Muscle tremors and other signs of hypomagnesemia

No bowel movement for 3 days Magnesium hydroxide is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. It would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

When planning nursing care for a patient with newly diagnosed diverticular disease, what is the most important goal for the nurse? 1 Identifying signs and symptoms of infection 2 Advising consumption of a diet high in fiber and protein 3 Restricting the patient's oral fluid intake to no more than 1 L/day 4 Limiting the patient's physical exercise to make it possible for the bowel to rest

Patients should be instructed to report signs and symptoms of infection or acute exacerbation of diverticulitis such as narrowed stools (resulting from inflammation) and mucus, pus, or blood mixed in the stool. Following the correct diet is also important with diverticular disorders; however, early detection and treatment of infection are higher priorities. There are no fluid or physical exercise restrictions to be recommended. 1

When teaching a patient with celiac disease about dietary changes, which food items should the nurse instruct this patient to restrict? Select all that apply. 1 Wheat 2 Rye 3 Barley 4 Oatmeal 5 Rice 6 Lentils

Patients with celiac disease are allergic to gluten and are advised to follow a gluten-free diet. Wheat, rye, barley, and oatmeal contain gluten and should be avoided by people who have celiac disease. Rice and lentils are gluten-free and are permitted in this diet. 1,2,3,4

A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? 1 Instruction on irrigating a colostomy 2 Administration of a cleansing enema 3 A high-fiber diet the day before surgery 4 Administration of intravenous (IV) antibiotics for bowel preparation

Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. A clear liquid diet will be used the day before surgery with the bowel cleansing. Oral antibiotics are given preoperatively and an intravenous (IV) antibiotic may be used in the operating room. Text Reference - p. 979 2

• With a bowel obstruction there is retention of fluid in the intestine and peritoneal cavity__

__which can result in a severe reduction in circulating blood volume and lead to hypotension and hypovolemic shock.

• Diverticula are

saccular dilations or outpouchings of the mucosa that develop in the colon at points where the vasa recta penetrate the circular muscle layer.

The nurse would incorporate what activities in implementing a plan of care for a patient experiencing fecal incontinence? 1 Bowel training 2 Exercise after meals 3 Use of stool softeners as a front-line treatment 4 Ingestion of a warm beverage, such as coffee, to enhance elimination

Regardless of the cause of fecal incontinence, bowel training is an effective strategy for many patients. Exercising after meals can aggravate symptoms of incontinence. Use of stool softeners is considered to stimulate anorectal reflex if bowel training is ineffective. Patients with fecal incontinence should avoid foods such as caffeine that worsen symptoms. 1

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? Notify the physician. Auscultate for bowel sounds. Reposition the tube and check for placement. Remove the tube and replace it with a new one.

Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The physician does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication? Take a dose of mineral oil at the same time. Add extra salt to food on at least one meal tray. Ensure a dietary intake of 10 g of fiber each day. Take each dose with a full glass of water or other liquid.

Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration? The patient must be able to see the site. The site should be outside the rectus muscle area. It is easier to seal the drainage bag to a protruding area. A waistline site will allow using a belt to hold the appliance in place.

The patient must be able to see the site. In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. Care should be taken to avoid skin creases, scars, and belt lines, which can interfere with the adherence of the appliance.

The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to a. increase fluid intake. b. administer an antibiotic. c. administer an antimotility drug. d. quarantine the patient to prevent spread of the virus.

a Rationale: Acute diarrhea resulting from infectious causes (e.g., virus) is usually self-limiting. The major concerns are transmission prevention, fluid and electrolyte replacement, and resolution of the diarrhea. Antidiarrheal agents are contraindicated in the treatment of infectious diarrhea because they potentially prolong exposure to the infectious organism. Antibiotics are rarely used to treat acute diarrhea. To prevent transmission of diarrhea caused by a virus, wash your hands before and after contact with the patient and when handling body fluids of any kind. Flush vomitus and stool down the toilet, and wash contaminated clothing immediately with soap and hot water.

• The patient with an ileostomy should be observed for

signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits.

The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the health care provider's preoperative prescriptions. The patient states that the health care provider has not explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? 1 Ask family members whether they have discussed the surgical procedure with the health care provider. 2 Have the patient sign the form and state that the health care provider will visit to explain the procedure before surgery. 3 Explain the planned surgical procedure as well as possible, and have the patient sign the consent form. 4 Delay the patient's signature on the consent and notify the health care provider about the conversation with the patient.

The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the health care provider, who has the responsibility for obtaining consent. If the patient states that the health care provider has not explained the procedure, there is no reason to ask the family if they spoke to the health care provider. It is unethical to have a patient sign a consent form unless they have a full understanding of the procedure. It is not within the nurse's scope of practice to explain a surgical procedure and obtain consent. The nurse may reinforce teaching. Text Reference - p. 969 4

The nurse is assessing a colostomy in a patient who had a colectomy 24 hours ago. Which of these assessment findings is considered normal for a new stoma? 1 Pale pink color 2 Dusky blue color 3 Brown or black color 4 Dark pink to red color

The stoma should be dark pink to red. The stoma should not be pale and pink. A dusky blue stoma indicates ischemia, and a brown-black stoma indicates necrosis. Assess and document stoma color every four hours and ensure that there is no excessive bleeding. Text Reference - p. 992 4

The inflammation of Crohn's disease involves __

__all layers of the bowel wall with segments of normal bowel occurring between diseased portions—the so-called skip lesions.

The primary symptoms of ulcerative colitis are __

__bloody diarrhea and abdominal pain.

• Fistulas are closed by

surgery or using fibrin glue. Postoperative and nursing care is the same as the patient with hemorrhoids.

The nurse determines a patient undergoing ileostomy surgery understands the procedure when the patient states a. "I should only have to change the pouch every 4 to 7 days." b. "The drainage in the pouch will look like my normal stools." c. "I may not need to wear a drainage pouch if I irrigate it daily." d. "Limiting my fluid intake should decrease the amount of output."

a Rationale: Because ileostomy drainage is a liquid to thin paste, the patient will need to wear a drainage bag at all times. The patient should use an open-ended drainable pouch. It is worn for 4 to 7 days. Output from a sigmoid colostomy resembles normally formed stool, and some patients are able to regulate emptying time so they do not need to wear an ostomy pouch.

The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu a. scrambled eggs and sausage. b. buckwheat pancakes with syrup. c. oatmeal, skim milk, and orange juice. d. yogurt, strawberries, and rye toast with butter.

a Rationale: Celiac disease is treated with lifelong avoidance of dietary gluten (wheat, barley, oats, rye products). Although pure oats do not contain gluten, oat products can become contaminated with wheat, rye, and barley during the milling process. Gluten is also found in some medications and in many food additives, preservatives, and stabilizers.

• Bowel sounds that are diminished or absent in a quadrant may indicate

a complete bowel obstruction, acute peritonitis, or paralytic ileus.

• Constipation can be defined as

a decrease in the frequency of bowel movements from what is "normal" for the individual; hard, difficult-to-pass stools; a decrease in stool volume; and/or retention of feces in the rectum.

• Peritonitis results from

a localized or generalized inflammatory process of the peritoneum.

o A nonmechanical obstruction may result from

a neuromuscular or vascular disorder. Vascular disorders are due to interference in the blood supply to the intestine.

• An anal fissure is

a skin ulcer or a crack in the lining of the anal wall that is caused by trauma, local infection, or inflammation.

• A pilonidal sinus is

a small tract under the skin between the buttocks in the sacrococcygeal area.

• Accurate diagnosis and management require

a thorough history, physical examination, and laboratory testing. Treatment depends on the cause.

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) a. persistent abdominal pain. b. marked abdominal distention. c. diarrhea that is loose or liquid. d. colicky, severe, intermittent pain. e. profuse vomiting that relieves abdominal pain.

a, b Rationale: With lower intestinal obstructions, abdominal distention is markedly increased and pain is persistent. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation, not diarrhea.

A 35-year-old female patient is admitted to the emergency department with acute abdominal pain. Which medical diagnoses should you consider as possible causes of her pain (select all that apply)? a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding d. Irritable bowel syndrome e. Inflammatory bowel disease

a, b, c, d, e Rationale: All these conditions could cause acute abdominal pain.

Assessment findings suggestive of peritonitis include (select all that apply) a. rebound tenderness. b. a soft, distended abdomen. c. dull, intermittent abdominal pain. d. shallow respirations with bradypnea. e. observing that the patient is lying still.

a, e Rationale: With peritoneal irritation, the abdomen is hard, and the patient has severe continuous abdominal pain that is worse with any sudden movement. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness. The patient lies very still and takes shallow breaths. Abdominal distention, tachypnea, fever, and tachycardia may occur.

• Short bowel syndrome (SBS) results from

surgical resection, congenital defect, or disease-related loss of absorption. The length and portions of small bowel affected are associated with the number and severity of symptoms.

• Familial adenomatous polyposis (FAP) is

the most common hereditary polyp disease.

• If the hernia becomes strangulated

the patient will experience severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention.

• The cause of IBS is

unknown and there are no specific findings.

• An ostomy is used

when the normal elimination route is no longer possible.

o Five major classes of medications are used to treat IBD:

aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, and biologic and targeted therapy.

• An anal fistula is

an abnormal tunnel leading from the anus or rectum, often into the vagina, or outside skin. They are often accompanied by infection and incontinence.

• Celiac disease is

an autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of wheat, barley, and rye in genetically susceptible individuals.

• Diarrhea is most commonly defined as

an increase in stool frequency or volume and an increase in the looseness of stool.

• Gastroenteritis is

an inflammation of the mucosa of the stomach and small intestine.

• Acute abdominal pain is a symptom of many different types of tissue injury

and can arise from damage to abdominal or pelvic organs and blood vessels.

• Other care for peritonitis includes

antibiotics, nasogastric suction, analgesics, and intravenous (IV) fluid administration.

• Crohn's disease can occur

anywhere in the GI tract from the mouth to the anus, but occurs most commonly in the terminal ileum and colon.

• If the causative agent of gastroenteritis is identified

appropriate antibiotic and antimicrobial drugs are given. Symptomatic nursing care is given for nausea, vomiting, and diarrhea.

• Gastrointestinal stromal tumors (GISTs)

are a rare form of cancer that originates in cells found in the wall of the GI tract.

In contrast to diverticulitis, the patient with diverticulosis a. has rectal bleeding. b. often has no symptoms. c. has localized cramping pain. d. frequently develops peritonitis.

b Rationale: Many people with diverticulosis have no symptoms. Patients with diverticulitis have symptoms of inflammation. Diverticulitis can lead to obstruction or perforation.

• Causes of malabsorption include

biochemical or enzyme deficiencies, bacterial proliferation, disruption of small intestine mucosa, disturbed lymphatic and vascular circulation, and surface area loss.

• Beginning at age 50

both men and women at average risk for developing CRC should have screening tests done to detect both polyps and cancer

A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that a. chemotherapy will begin after the patient recovers from the surgery. b. both chemotherapy and radiation can be used as palliative treatments. c. follow-up colonoscopies will be needed to ensure that the cancer does not recur. d. a wound, ostomy, and continence nurse will visit the patient to identify an abdominal site for the ostomy.

c Rationale: Stage I colorectal cancer is treated with surgical removal of the tumor and reanastomosis, and so there is no ostomy. Chemotherapy is not recommended for stage I tumors. Follow-up colonoscopy is recommended because colorectal cancer can recur.

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease a. frequently results in toxic megacolon. b. causes fewer nutritional deficiencies than ulcerative colitis. c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. d. is manifested by rectal bleeding and anemia more often than is ulcerative colitis.

c Rationale: Ulcerative colitis affects only the colon and rectum; it can cause megacolon and rectal bleeding, but not nutrient malabsorption. Surgical removal of the colon and rectum cures it. Crohn's disease usually involves the ileum, where bile salts and vitamin cobalamin are absorbed. After surgical treatment, disease recurrence at the site is common.

• Treatment of lactase deficiency consists of

eliminating lactose from the diet by avoiding milk and milk products and/or replacement of lactase with commercially available preparations.

• Emergency management of abdominal trauma focuses on

establishing a patent airway and adequate breathing, fluid replacement, and prevention of hypovolemic shock.

• There are numerous causes of constipation. Clinical presentation varies from

chronic discomfort to an acute event, often depending on cause.

• Anorectal abscesses are

collections of perianal pus resulting from an infection in the anal glands.

• Risk factors for fecal incontinence include

constipation, diarrhea, obstetrical trauma, and fecal impaction.

• SBS is characterized by

failure to maintain protein-energy, fluid, electrolyte, and micronutrient balances on a standard diet; it may be accompanied by diarrhea.

• Classic signs of celiac disease include

foul-smelling diarrhea, steatorrhea, flatulence, abdominal distention, and symptoms of malnutrition.

What should a patient be taught after a hemorrhoidectomy? a. Take mineral oil before bedtime. b. Eat a low-fiber diet to rest the colon. c. Administer oil-retention enema to empty the colon. d. Use prescribed pain medication before a bowel movement.

d Rationale: After a hemorrhoidectomy, the patient usually dreads the first bowel movement and often resists the urge to defecate. Give pain medication before the bowel movement to reduce discomfort. The patient should avoid constipation and straining. A high-fiber diet can reduce constipation. A stool softener such as docusate (Colace) is usually ordered for the first few postoperative days. If the patient does not have a bowel movement within 2 to 3 days, an oil-retention enema is administered.

A nursing intervention that is most appropriate to decrease postoperative edema and pain after an inguinal herniorrhaphy is a. applying a truss to the hernia site. b. allowing the patient to stand to void. c. supporting the incision during coughing. d. applying a scrotal support with an ice bag.

d Rationale: Scrotal edema is a painful complication after an inguinal hernia repair. Scrotal support with application of an ice bag may help relieve pain and edema.

• Diarrhea can result from alterations in

gastrointestinal motility, increased secretion, and decreased absorption.

• Three factors necessary for the development of celiac disease (gluten intolerance) are

genetic predisposition, gluten ingestion, and an immune-mediated response.

• During an acute exacerbation of IBD nursing care is focused on

hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support.

o Mechanical obstruction is a

detectable occlusion of the intestinal lumen. Most intestinal obstructions occur in the small intestine.

• SBS is treated with

dietary changes, supplements, and antidiarrheal medications.

• Hemorrhoids are

dilated hemorrhoidal veins. They may be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter).

• Inflammation of the appendix with obstruction results in

distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene and perforation.

• Surgery for peritonitis is usually indicated to

drain purulent fluid and repair damage.

The nurse has provided teaching to a patient who has diverticular disease but is not experiencing an acute episode at this time. Which statement by the patient reflects an adequate understanding of the teaching? 1 "I will eat a diet that is low in fiber." 2 "I will avoid eating nuts and seeds." 3 "I will decrease my intake of fat and red meat." 4 "I will continue to work out by lifting weights."

A high-fiber diet, mainly from fruits and vegetables, and decreased intake of fat and red meat are recommended for preventing diverticular disease. High levels of physical activity also seem to decrease the risk. A high-fiber diet also is recommended once diverticular disease is present. Currently there is no evidence to support the theory that diverticulitis can be prevented by avoiding nuts and seeds. A patient with diverticular disease should avoid increased intraabdominal pressure because it may precipitate an attack. Factors that increase intraabdominal pressure are straining at stool, vomiting, bending, lifting, and wearing tight restrictive clothing. Text Reference - p. 995 3

The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer? 1 Osteoarthritis 2 History of colorectal polyps 3 History of lactose intolerance 4 Use of herbs as dietary supplements

A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risks to the patient. Text Reference - p. 986 2

A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 am. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 1 7:00 am, 10:00 am, and 1:00 pm 2 8:00 am, 12:00 pm, and 4:00 pm 3 9:00 am and 3:00 pm 4 9:00 am, 12:00 pm, and 3:00 pm

A nasogastric tube should be checked for patency routinely at four-hour intervals. Thus if the tube were inserted at 4:00 am, it would be due to be checked at 8:00 am, 12:00 pm, and 4:00 pm. Text Reference - p. 984 2

A patient's colostomy stoma is scheduled to be irrigated on the fifth postoperative day. What does the nurse understand to be the main purpose of the irrigation? 1 Act as an enema 2 Help regulate the colon 3 Remove any blood clots 4 Assess the patency of the colostomy

A new colostomy may require irrigation to train, or regulate, the colon for its modified function. The patient should also be instructed to contract abdominal muscles and to massage the abdomen from right to left to stimulate peristalsis. Although colostomy irrigation may act as an enema to facilitate a bowel movement, its greater purpose is the regulation of the colon. Blood clots should not be present, and an irrigation is never used to test the patency of the colostomy. Text Reference - p. 992 2

A patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. . b. prepare for colonoscopy. c. schedule a barium enema d. have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. DIF: Cognitive Level: Apply (application) REF: 931 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.

A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the prescribed IV morphine sulfate. d. Offer the prescribed promethazine (Phenergan).

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention. DIF: Cognitive Level: Analyze (analysis) REF: 940 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS. DIF: Cognitive Level: Apply (application) REF: 940 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

A patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. DIF: Cognitive Level: Apply (application) REF: 947 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery. DIF: Cognitive Level: Analyze (analysis) REF: 941 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur. DIF: Cognitive Level: Apply (application) REF: 949 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA. DIF: Cognitive Level: Understand (comprehension) REF: 955 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. DIF: Cognitive Level: Apply (application) REF: 935 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

The nurse is teaching medication safety measures to a patient who is receiving docusate. Which statement by the patient indicates effective learning? 1 "I should avoid eating spinach." 2 "I should eat more foods rich in vitamin K." 3 "I should avoid products that contain magnesium." 4 "I should take the medication with 250 mL of grapefruit juice."

Docusate is a stool softener and lubricant. It reduces the absorption of vitamin K and increases risk of bleeding. Therefore, the nurse should instruct the patient to increase the intake of vitamin K-rich food. Spinach is a rich source of vitamin K, so the nurse should instruct the patient to include dark-green leafy vegetables like spinach in the diet. Docusate does not cause hypermagnesemia. Therefore, the nurse does not recommend that the patient avoid magnesium intake. Grapefruit juice decreases metabolism of drug, so the nurse does not instruct the patient to take the medication with grapefruit juice. Text Reference - p. 967 2

The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? 1 The patient must be able to see the site. 2 Outside the rectus muscle area is the best site. 3 It is easier to seal the drainage bag to a protruding area. 4 The ostomy will need irrigation so the area should not be tender.

In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. 1

The nurse should administer an as needed dose of magnesium hydroxide (Milk of Magnesia) after noting what information while reviewing a patient's medical record? 1 Abdominal pain and bloating 2 No bowel movement for three days 3 A decrease in appetite by 50% over 24 hours 4 Muscle tremors and other signs of hypomagnesemia

Magnesium hydroxide is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for three days. Magnesium hydroxide would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia. 2

The nurse performs a detailed health history for a patient with a possible bowel obstruction. Which of these are manifestations of an obstruction in the small intestine? Select all that apply. 1 Rapid onset 2 Absolute constipation 3 Frequent, copious vomiting 4 Colicky, cramplike, intermittent pain 5 Low-grade, cramping abdominal pain

Manifestations of an obstruction in the small intestine include rapid onset, frequent and copious vomiting, colicky, cramplike, intermittent pain, production of feces for a short time, and greatly increased abdominal distension. Absolute constipation and low-grade, cramping abdominal pain are manifestations of an obstruction of the large intestine. Text Reference - p. 983 1,3,4

A nurse performs an abdominal assessment and notes that a patient has tenderness over the McBurney point. Identify the area where the nurse elicits this finding.

The McBurney point is the area in the region of the right lower quadrant of the abdomen. It is the landmark for pain associated with appendicitis.

The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. The patient has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? 1 "The tube will help to drain the stomach contents and prevent further vomiting." 2 "The tube will push past the area that is blocked and thus help to stop the vomiting." 3 "The tube is just a standard procedure before many types of surgery to the abdomen." 4 "The tube will let us measure your stomach contents so that we can plan what type of intravenous (IV) fluid replacement would be best."

The NG tube is used to decompress the stomach by draining stomach contents, and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not indicated currently. The location of the obstruction will determine the type of fluid to use, not measuring the amount of stomach contents. 1

A patient is brought to the emergency department after a motor vehicle accident. On examination, the nurse finds that patient has sustained facial trauma and suspects a fractured pelvis. The nurse also notes a large piece of glass is impaled in the abdomen. What nursing actions are appropriate for this patient? 1 Insert a nasogastric tube. 2 Remove the impaled piece of glass. 3 Insert an indwelling urinary catheter. 4 Ensure a patent airway.

The first step after receiving any patient after a motor vehicle injury is to ensure a patent airway and ensure that the patient is breathing. A nasogastric tube should be inserted if there is no facial trauma. Any impaled object should be stabilized with bulky dressing, but should not be removed, in order to prevent further injury and bleeding. If the patient has sustained a fractured pelvis, inserting a urinary catheter is not advised. Text Reference - p. 973 4

In planning care for a patient with fecal incontinence, the goal the nurse is likely to establish is the patient will 1 Eliminate once a day 2 Maintain perianal skin integrity 3 Cope with depression by having alone time 4 Alleviate all nonessential work and social activities

The overall goals are that the patient with fecal incontinence will have predictable bowel elimination, maintain perianal skin integrity, participate in work and social activities, and avoid self-esteem problems related to bowel control. Elimination could occur more than once a day as long as it is predictable. Stool and moisture from stool left on the skin can cause impairment to the skin's integrity. Text Reference - p. 965 2

A postoperative patient is being discharged from the hospital following a surgery for Crohn's disease. The nurse understands that the patient is at risk for bowel obstruction. What early symptoms of bowel obstruction should the nurse advise this patient to be observant for? Select all that apply. 1 Constipation 2 Decreased flatus 3 Colicky abdominal pain 4 Nausea and vomiting 5 Abdominal distention

The patient should be watchful for symptoms such as a colicky abdominal pain, nausea and vomiting, and abdominal distention. These are symptoms of bowel obstruction. Constipation and decreased flatus occur later. 3,4,5

The nurse is discussing postoperative care with a patient who had inguinal hernia repair the previous day. Which statement by the patient reflects a need for additional education? 1 "If I have to cough, I will cough with my mouth open." 2 "I will place an ice bag against my scrotum for support." 3 "I will hold a pillow against my incision if I have to sneeze" 4 "I can go back to my job at the moving company in four weeks."

The statement about returning to work at the moving company does not reflect an adequate understanding of instructions. The patient may be restricted from heavy lifting for six to eight weeks. After a hernia repair, encourage deep breathing, but not coughing. Teach patients to splint the incision and keep their mouths open when coughing or sneezing is unavoidable. Scrotal edema is a painful complication and scrotal support with application of an ice bag may help relieve pain and edema. Text Reference - p. 996 4

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of: 1 Impaired peristalsis 2 Irritation of the bowel 3 Nasogastric suctioning 4 Inflammation of the incision site

Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention. 1

The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? 1 Write an incident report about this untoward event. 2 Attempt to have the family convince the patient to take the prescribed dose. 3 Withhold the medication at this time and try to administer it later in the day. 4 Chart the dose as not given on the medical record and explain in the nursing progress notes.

Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient and the patient should not be encouraged to take it today. The nurse should not have the family convince the patient to take the magnesium hydroxide. An incident report is not necessary in this instance. If the patient is having loose stools, they will likely not need the docusate sodium later during the day. 4

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