Chapter 46: Bowel Elimination

List the correct order in which to apply an ostomy pouch: 1. Remove the used pouch and skin barrier 2. Perform hand hygiene, and apply clean gloves 3. Asses the stoma for color, swelling, and healing 4. Gently cleanse the peristomal skin with warm tap water 5. Apply nonallergenic tape around the pectin skin barrier 6. Cut an opening on the pouch 1/16 inch larger than the stoma 7. Press the adhesive backing of the pouch smoothly against the skin

2. Perform hand hygiene, and apply clean gloves 1. Remove the used pouch and skin barrier 3. Assess the stoma for color, swelling, and healing 4. Gently cleanse the peristomal skin with warm tap water 6. Cut an opening on the pouch 1/16 inch larger than the stoma 5. Apply nonallergenic tape around the pectin skin barrier 7. Press adhesive backing of the pouch smoothly against the skin

Number the steps to irrigating a nasogastric tube in correct order: 1. Slowly aspirate the syringe 2. Reconnect the NG tube to suction 3. Clamp and disconnect the NG tube 4. Perform hand hygiene, and apply clean gloves 5. Insert tip of syringe into NG tube, and slowly inject 30 mL saline

4. Perform hand hygiene, and apply clean gloves 5. Insert tip of syringe into NG tube, and slowly inject 30 mL saline 2. Reconnect the NG tube to suction 1. Slowly aspirate the syringe 3. Clamp and disconnect the NG tube

A nurse teaches a client experiencing heartburn to take 1 ½ oz of Maalox when symptoms appear. How many milliliters should the client take? ______ mL.

45 mL

A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? A. "I can use a fleet enema to save money because it contains the same irrigation solution." B. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." C. "I should never attempt to reach into my stoma to remove fecal material." D. "Using warm tap water will reduce cramping and discomfort during the procedure."

A. "I can use a fleet enema to save money because it contains the same irrigation solution." Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? A. "If I get a positive result, I have gastrointestinal bleeding." B. "I should not eat red meat before my examination." C. "I should schedule to perform the examination when I am not menstruating." D. "I will need to perform this test three times if I have a positive result."

A. "If I get a positive result, I have gastrointestinal bleeding." A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.

Which of the following is not a function of the large intestine? A. Absorbing nutrients B. Absorbing water C. Secreting bicarbonate D. Eliminating waste

A. Absorbing nutrients Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine.

The nurse would expect the least formed stool to be present in which portion of the digestive tract? A. Ascending B. Descending C. Transverse D. Sigmoid

A. Ascending The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool would be in the ascending.

The nurse is obtaining a client's medication history. Which of the following medications my cause gastrointestinal bleeding? (Select all that apply.) A. Aspirin B. Cathartics C. Antidiarrheal opiate agents D. Nonsteroidal anti-inflammatory drugs (NSAIDS)

A. Aspirin D. NSAIDS

The nurse knows that the ideal time to change an ostomy pouch is: A. Before eating a meal, when the patient is comfortable B. When the patient feels that he needs to have a bowel movement C. When ordered in the patient's chart D. After the patient has ambulated the length of the hallway

A. Before eating a meal, when the patient is comfortable The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.

The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? A. Bowel sounds B. Presence of flatulence C. Bowel movements D. Nausea

A. Bowel sounds The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.

Which class of laxative acts by causing the stool to absorb water and swell? A. Bulk-forming B. Emollient C. Lubricant D. Stimulant

A. Bulk-forming Emollients lubricate the stool. Lubricants soften the stool, making it easier to pass. Stimulants promotes peristalsis by irritating the intestinal mucosa or stimulating nerve ending in the intestinal wall.

Which of the following is a true statement about the effects of medication on bowel illumination? A. Diarrhea commonly occurs with amoxicillin clavulanate use B. Anticoagulants cause a white discoloration of the stool C. Narcotic analgesics increased gastrointestinal mobility D. Iron salts in pair digestion and cause a green store

A. Diarrhea commonly occurs with amoxicillin clavulanate use Anticoagulants may result in the stool having a pink to red to black appearance, whereas iron salts also cause a black stool. Narcotic analgesics decrease gastric mobility.

After a patient returns from a barium swallow, the nurse's priority is to: A. Encourage the patient to increase fluids to flush out the barium B. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure C. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times D. Thicken all patient drinks to prevent aspiration

A. Encourage the patient to increase fluids to flush out the barium Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.

The nurse instructs the client to avoid which of the following foods, which could give a false reading on the fecal occult blood test? (Select all the apply.) A. Fish B. Lasagna C. Cranberry juice D. Raw vegetables

A. Fish D. Raw vegetables

To prevent the client from performing Valsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.) A. Glaucoma B. Hypotension C. Cardiovasular disease D. Risk for increased intracranial pressure

A. Glaucoma C. Cardiovascular disease D. Risk for increased intracranial pressure

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Grape and walnut chicken salad sandwich on whole wheat bread B. Broccoli and cheese soup with potato bread C. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing D. Turkey and mashed potatoes with brown gravy

A. Grape and walnut chicken salad sandwich on whole wheat bread A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? A. Hypoactive bowel sounds B. Jaundice in sclera C. Decreased skin turgor D. Soft tender abdomen

A. Hypoactive bowel sounds Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation.

The nurse should place the patient in which position when preparing to administer an enema? A. Left Sims' position B. Fowler's C. Supine D. Semi-Fowler's

A. Left Sims' position Side-lying Sims' position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that: A. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur B. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis C. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation D. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced

A. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? A. Lubricating the nares with water-soluble lubricant B. Applying a small ice bag to the nose for 5 minutes every 4 hours C. Instilling Xylocaine into the nares once a shift D. Changing the tape holding the tube in place once a shift

A. Lubricating the nares with water-soluble lubricant The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? (Select all that apply.) A. Obtain adequate rest to reduce stimulation B. Eat small, frequent meals throughout the day C. Take all medications on time as ordered D. Sit up for one hour when awakened at night E. Stay away from crowded areas

A. Obtain adequate rest to reduce stimulation B. Eat small, frequent meals throughout the day C. Take all medications on time as ordered D. Sit up for one hour when awakened at night The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? A. Positioning the patient in the dorsal recumbent position with a bed pan B. Assisting the patient to the bedside commode C. Stopping the enema cleansing and rolling the patient into right-lying Sims' position D. Inserting a rectal plug to contain the enema solution

A. Positioning the patient in the dorsal recumbent position with a bed pan Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? A. Promptly assess the client for potential perforation B. Tell the assistant to change thermometers and retake the temperature C. Plan to give the client acetaminophen (Tylenol) to lower the temperature D. Ask the assistant to bathe the client with tepid water

A. Promptly assess the client for potential perforation A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a physician's order; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

A barium enema should be done before an upper gastrointestinal series because of which of the following? A. Retained barium may cloud the colon B. Barium can cause lower gastrointestinal bleeding C. The physicians orders are in that sequence D. Barium is absorbed readily in the lower intestine

A. Retained barium may cloud the colon

A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? A. Salem sump B. Dobhoff C. Sengstaken-Blakemore D. Small bore

A. Salem sump A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.

The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10 days when which of the following occurs: (Select all that apply.) A. The client feels nauseated B. The client oozes liquid stool C. The client has a rounded abdomen D. The client has continuous bowel sounds

A. The client feels nauseated B. The client oozes liquid stool D. The client has continuous bowel bounds

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? A. The patient reports eliminating a soft, formed stool B. The patient has quit taking opioid pain medication C. The patient's lower left quadrant is tender to the touch D. The nurse hears bowel sounds present in all four quadrants

A. The patient reports eliminating a soft, formed stool The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? A. "This is probably a false negative; we should rerun the test." B. "Do you take iron supplements?" C. You should schedule a colonoscopy as soon as possible." D. "Sometimes severe stress can alter stool color."

B. "Do you take iron supplements?" Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.

Which patient is most at risk for increased peristalsis? A. A 5 year old child who ignores the urge to defecate owing to embarrassment B. A 21 year old patient with three final examinations on the same day C. A 40 year old woman with major depressive disorder D. An 80 year old man in an assisted-living environment

B. A 21 year old patient with three final examinations on the same day Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.

When irrigating a colostomy, the nurse is sure to use which of the following equipment?: A. An enema set B. A cone-tipped irrigator C. A 50 mL irrigation syringe D. A 16-French Foley catheter with a 30 mL balloon

B. A cone-tipped irrigator

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: A. Involvement with his job will keep the client from becoming bored B. A relaxed environment will promote ulcer healing C. Not keeping up with his job will increase the client's stress level D. Setting limits on the client's behavior is an important nursing responsibility

B. A relaxed environment will promote ulcer healing A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes.

If the patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? A. Chinese B. Alcohol C. Eggs D. Pasta

B. Alcohol

An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should: A. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap B. Apply a skin protective lotion after perineal care C. Tape an occlusive moisture barrier pad to the patient's skin D. Massage the skin with deep kneading pressure

B. Apply a skin protective lotion after perineal care Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.

The nurse teaches clients with a new colostomy that they can eat whatever roods they like but that which of the follwing foods typically produce gas and should be consumed cautiously? (Select all that apply) A. Pasta B. Beans C. Garlic D. Onions E. Cauliflower

B. Beans D. Onions E. Cauliflower

The nurse is instructing the client about the use of opioids for pain relief. Included in the teaching is the fact that opioids may cause: A. Headaches B. Constipation C. Hypertension D. Muscle weakness

B. Constipation

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping related to fear of diagnosis of chronic illness B. Deficient knowledge related to unfamiliarity with significant signs and symptoms C. Constipation related to decreased gastric motility D. Imbalanced nutrition: Less than body requirements related to gastric bleeding

B. Deficient knowledge related to unfamiliarity with significant signs and symptoms Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. The data do not support the other diagnoses.

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? A. Preparing the patient for a second tap water enema B. Donning gloves for digital removal of the stool C. Positioning the patient on the left side D. Inserting a rectal tube

B. Donning gloves for digital removal of the stool When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.

The nurse knows that most nutrients are absorbed in which portion of the digestive tract? A. Stomach B. Duodenum C. Ileum D. Cecum

B. Duodenum Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.

Soon after the client's abdominal surgery the nurse includes in the plan of care which of the follwing interventions, which is essential for promoting peristalsis? A. Consumption of a high-fiber diet B. Early ambulation C. Restriction of fluid intake D. Administration of large doses of opioids

B. Early ambulation

Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: A. Demonstrate appropriate use of analgesics to control pain. B. Explain the rationale for eliminating alcohol from the diet C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months D. Eliminate contact sports from his or her lifestyle

B. Explain the rationale for eliminating alcohol from the diet Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because: A. The digested food needs to make room for recently ingested food B. Mastication triggers the digestive system to begin peristalsis C. The smell of bowel elimination in the room would deter the patient from eating D. More ancillary staff members are available after meal times

B. Mastication triggers the digestive system to begin peristalsis Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patient's voiding schedule should not be based on the staff's convenience.

A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? (Select all that apply.) A. Administering an antacid hourly until nausea subsides B. Monitoring the client's vital signs C. Notifying the physician of the client's symptoms D. Initiating oxygen therapy E. Reassessing the client in an hour

B. Monitoring the client's vital signs C. Notifying the physician of the client's symptoms The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the physician of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? A. Liquid consistency of stool B. Presence of blood in the stool C. Noxious odor from the stool D. Continuous output from the stoma

B. Presence of blood in the stool Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? A. Administering laxatives to the patient B. Raising the head of the bed C. Preparing to administer a barium enema D. Withholding narcotic pain medication

B. Raising the head of the bed Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.

A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? A. Ensuring that the patient does not eat or drink 2 hours before the examination B. Removing all of the patient's metallic jewelry C. Administering a colon cleansing product 12 hours before the examination D. Obtaining an order for a pain medication before the test is performed

B. Removing all of the patient's metallic jewelry No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? A. Changing the skin barrier portion of the ostomy pouch daily B. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying C. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive D. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

B. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

Which physiological change can cause a paralytic ileus? A. Chronic cathartic abuse B. Surgery for Crohn's disease and anesthesia C. Suppression of hydrochloric acid from medication D. Fecal impaction

B. Surgery for Crohn's disease and anesthesia Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.

The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? (Select all that apply.) A. The client has a sore throat B. The client has a temperature of 100 ° F (37.8 ° C) C. The client appears drowsy following the procedure D. The client has epigastric pain E. The client experiences hematemesis

B. The client has a temperature of 100 ° F (37.8 ° C) D. The client has epigastric pain E. The client experiences hematemesis Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? A. They will cause a fecal impaction B. They will cause chronic constipation C. They change the pH of the gastrointestinal track D. They inhibit the intestinal enzymes

B. They will cause chronic constipation

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? A. Elevate the head of the bed 45 degrees 60 minutes after breakfast B. Use a mobility device to place the patient on a bedside commode C. Give the patient a pillow to brace against the abdomen while bearing down D. Administer a soap suds enema every 2 hours

B. Use a mobility device to place the patient on a bedside commode The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patient's condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? A. Visual examination of the esophagus and stomach B. Visual examination of the large intestine C. Radiographic examination of the large intestine D. Fluoroscopic examination of the small intestine

B. Visual examination of the large intestine

The nurse should question which order? A. A normal saline enema to be repeated every 4 hours until stool is produced B. A hypertonic solution enema with a patient with fluid volume excess C. A Kayexalate enema for a patient with hypokalemia D. An oil retention enema for a patient using mineral oil laxatives

C. A Kayexalate enema for a patient with hypokalemia Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.

The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? A. The client awaiting hiatal hernia repair at 11 am B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests C. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw

C. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw B. A client with suspected gastric cancer who is on NPO status for tests A. The client awaiting hiatal hernia repair at 11 am The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? A. Bland foods B. High-protein foods C. Any foods that are tolerated D. Large amounts of milk

C. Any foods that are tolerated Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

In assessing a 55 year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to proved a stool specimen for guaiac fecal occult blood testing: A. If the client notices rectal bleeding B. If there is a family history of intestinal polyps C. As part of a routine screening for colon cancer D. If a palpable mass is detected on digital exam

C. As part of a routine screening for colon cancer

A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? A. Before meals B. With meals C. At bedtime D. When pain occurs

C. At bedtime Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? A. Increased energy levels B. Distended abdomen C. Decreased serum bicarbonate D. Increased blood pressure

C. Decreased serum bicarbonate Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.

A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? A. Rectal skin breakdown B. Contamination of existing wounds C. Falls from attempts to reach the bathroom D. Cross-contamination into the upper GI tract

C. Falls from attempts to reach the bathroom The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.

The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient: A. Has a decreased level of anxiety B. Experiences pain relief C. Has a bowel movement D. Passes flatulence

C. Has a bowel movement A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic.

Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention enema by doing which of the following? A. Administering a large volume solution 500 to 1000 ml B. Mixing milk and molasses and equal parts for an enema C. Instructing the patient to retain the enema for at least 30 seconds D. Administering the enema while the patient is sitting on a toilet

C. Instructing the patient to retain the enema for at least 30 seconds

A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail". Which nursing actions would be appropriate for the nurse to implement at this time? (Select all that apply.) A. Clamp the blue pigtail B. Attach suction to the blue pigtail. C. Irrigate the large lumen with saline D. Position the blu pigtail at the level of the client's ear

C. Irrigate the large lumen with saline

During the nursing assessment the client revels that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold termperature of the food. However, the nurse begins to suspect the these symptoms might be associated with: A. Food allergy B. Irritable bowel C. Lactose intolerance D. Increased peristalsis

C. Lactose intolerance

The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by: A. Applying liberal amounts of stool to the guaiac paper B. Testing the quality control section before collecting the specimen section C. Reporting any abnormal findings to the provider D. Applying sterile disposable gloves

C. Reporting any abnormal findings to the provider Abnormal findings such as a positive test should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.

During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurse's next action is to: A. Stop the instillation B. Slow down the rate of instillation C. Stop the instillation and measure vital signs D. Tell the client to breathe

C. Stop the instillation and measure vital signs

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? A. The client has not been including enough fiber in his diet B. The client needs to increase his daily exercise C. The client is experiencing an adverse effect of the aluminum hydroxide D. The client has developed a gastrointestinal obstruction

C. The client is experiencing an adverse effect of the aluminum hydroxide It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? A. Eggs over easy, whole wheat toast, and orange juice with pulp B. Chicken fried rice with stir fried vegetables and iced tea C. Turkey meatloaf with white rice and apple juice D. Fish sticks with macaroni and cheese and soda

C. Turkey meatloaf with white rice and apple juice During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.

The nurse would anticipate which diagnostic examination for a patient with black tarry stools? A. Ultrasound B. Barium enema C. Upper endoscopy D. Flexible sigmoidoscopy

C. Upper endoscopy Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.

When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? (Select all that apply.) A. Epigastric pain at night B. Relief of epigastric pain after eating C. Vomiting D. Weight loss E. Melena

C. Vomiting D. Weight loss E. Melena Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.

A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? A. "I should take my antacid before I take my other medications." B. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." C. "My antacid will be most effective if I take it whenever I experience stomach pains." D. "It is best for me to take my antacid 1 to 3 hours after meals."

D. "It is best for me to take my antacid 1 to 3 hours after meals." Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain

A cleansing enema is ordered for a 55 year-old client before intestinal surgery. The maximum amount of fluid used is: A. 150 to 200 mL B. 200 to 400 mL C. 400 to 750 mL D. 750 to 1000 mL

D. 750 to 1000 mL

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? A. A 40 year old patient with an ileostomy B. A 25 year old patient with Crohn's disease C. A 30 year old patient with C. difficile D. A 70 year old patient with stool incontinence

D. A 70 year old patient with stool incontinence A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohn's disease, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

A nurse trained to care for ostomy clients is: A. A gastrointestinal therapist B. A nurse practitioner C. An ostomy practitioner D. A wound-ostomy-continence nurse

D. A wound-ostomy-continence nurse

A guaiac test has been ordered. The nurse knows that this is a test for: A. Bright red blood B. Dark black blood C. Blood that contains mucus D. Blood that cannot be seen

D. Blood that cannot be seen Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? A. Conduct physical activity in the morning so that he can rest in the afternoon B. Have the family agree to perform the necessary yard work at home C. Give up jogging and substitute a less demanding hobby D. Incorporate periods of physical and mental rest in his daily schedule

D. Incorporate periods of physical and mental rest in his daily schedule It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.

A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug? A. Heal the ulcer B. Protect the ulcer surface from acids C. Reduce acid concentration D. Limit gastric acid secretion

D. Limit gastric acid secretion Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretory, or proton-pump inhibitors, such as omeprazole (Prilosec), help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate (Carafate), protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? A. Monthly in-services about contact precautions B. Placing all contaminated items in biohazard bags C. Mandatory cultures on all patients D. Proper hand hygiene techniques

D. Proper hand hygiene techniques Proper hand hygiene is the best way to prevent the spread of bacteria. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.

Fecal impactions occur in which portion of the colon? A. Ascending B. Descending C. Transverse D. Rectum

D. Rectum A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

A client who recently experience a bout of diarrhea is requesting something to drink. There is an order to force clear liqueids to prevent fluid and electrolyte imbalance. The nurse decides to give the client: A. Ice cream B. A cold fruit pop C. A cup of hot coffee D. Room-temperature bouillon

D. Room-temperature bouillon

Diarrhea that occurs with a fecal impaction is the result of: A. A clear liquid diet B. Irritation of the intestinal mucosa C. Inability of the client to form a stool D. Seepage of stool around the impaction

D. Seepage of stool around the impaction

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? A. Stoma is protruding from the abdomen B. Stoma is moist C. Stool is discharging from the stoma D. Stoma is purple

D. Stoma is purple A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.

A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? A. Oil retention B. Carminative C. Saline D. Tap water

D. Tap water Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.

Most nutrients and electrolytes are absorbed in: A. The colon B. The stomach C. The esophagus D. The small intestine

D. The small intestine

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, board-like abdomen. These clinical manifestations most likely indicate which of the following? A. An intestinal obstruction has developed B. Additional ulcers have developed C. The esophagus has become inflamed D. The ulcer has perforated

D. The ulcer has perforated The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause mid-epigastric pain. The development of additional ulcers or esophageal inflammation would not cause a rigid, board-like abdomen.