Chapter 56

Question 1

1. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?
   a. Ham sandwich on white bread, cup of applesauce, glass of diet cola
   b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice
   c. Grilled cheese sandwich, small banana, cup of hot tea with lemon
   d. Baked tilapia, fresh green beans, cup of co ee with low-fat milk

Answer 1

ANS: B
Clients with IBS are advised to eat a high-ber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest ber content. They should avoid alcohol, caeine, and other gastric irritants.

Question 2

2. A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?
   a. “Have you been experiencing any constipation?”
   b. “Are you eating a diet high in ber and uids?”
   c. “Do you have a history of high blood pressure?”
   d. “What vitamins and supplements are you

Answer 2

ANS: A
Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipa- tion. The other questions do not identify complications related to alosetron.

Question 3

4. A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the dis- tended area. Which action should the nurse take?
   a. Assess the client’s heart rate and blood pressure.
   b. Determine when the client last voided.
   c. Ask if the client is experiencing atus.
   d. Auscultate all quadrants of the client’s abdomen.

Answer 3

ANS: B
Assessment ndings indicate that the client may have an over-full bladder. In the immediate postoperative peri- od, the client may experience diculty voiding due to urinary retention. The nurse should assess when the client last voided. The client’s vital signs may be checked after the nurse determines the client’s last void. Asking about atus and auscultating bowel sounds are not related to a hemorrhoidectomy.

Question 4

5. A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer?
   a. A 37-year-old who drinks eight cups of co ee daily
   b. A 44-year-old with irritable bowel syndrome (IBS)
   c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

Answer 4

ANS: D
Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in ber, increasing the risk for colon cancer. Co ee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

Question 5

6. A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the pres- ence of visible peristaltic waves. Which action should the nurse take?
   a. Ask if the client is experiencing pain in the right shoulder.
   b. Perform a rectal examination and assess for polyps.
   c. Contact the provider and recommend computed tomography.
   d. Administer a laxative to increase bowel movement activity.

Answer 5

ANS: C
The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recom- mend a computed tomography scan for further diagnostic testing. This assessment nding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualied to complete a rectal examination for polyps, and laxatives would not help this client.

Question 6

7. A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, “My doctor told me that the fecal occult blood test was negative for colon cancer. I don’t think I need the colonoscopy and would like to cancel it.” How should the nurse respond?
   a. “Your doctor should not have given you that information prior to the colonoscopy.”
   b. “The colonoscopy is required due to the high percentage of false negatives with the blood test.” c. “A negative fecal occult blood test does not rule out the possibility of colon cancer.”
   d. “I will contact your doctor so that you can discuss your concerns about the procedure.”

Answer 6

ANS: C
A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client’s concerns prior to contacting the provider.

Question 7

8. A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family mem- bers. Which action should the nurse take?
   a. Contact the provider and recommend a psychiatric consult for the client.
   b. Encourage the client to verbalize feelings about the diagnosis.
   c. Provide education about new treatment options with successful outcomes.
   d. Ask family and friends to visit the client and provide emotional support.

Answer 7

ANS: B
The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client’s feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support.

Question 8

9. A nurse cares for a client with colon cancer who has a new colostomy. The client states, “I think it would be helpful to talk with someone who has had a similar experience.” How should the nurse respond?
   a. “I have a good friend with a colostomy who would be willing to talk with you.”
   b. “The enterostomal therapist will be able to answer all of your questions.”
   c. “I will make a referral to the United Ostomy Associations of America.”
   d. “You’ll nd that most people with colostomies don’t want to talk about them.”

Answer 8

ANS: C
Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client’s request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

Question 9

10. An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client’s lower abdomen. Which action should the nurse take rst?
    a. Measure the client’s abdominal girth.
    b. Assess for abdominal guarding or rigidity.
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    c. Check the client’s hemoglobin and hematocrit.
    d. Obtain the client’s complete health history.

Answer 9

ANS: B
On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, be- cause this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

Question 10

11. A nurse cares for a client who states, “My husband is repulsed by my colostomy and refuses to be intimate with me.” How should the nurse respond?
    a. “Let’s talk to the ostomy nurse to help you and your husband work through this.”
    b. “You could try to wear longer lingerie that will better hide the ostomy appliance.”
    c. “You should empty the pouch rst so it will be less noticeable for your husband.”
    d. “If you are not careful, you can hurt the stoma if you engage in sexual activity.”

Answer 10

ANS: A
The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client’s concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

Question 11

12. A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, “I need to have a bowel movement.” Which action should the nurse take?
    a. Obtain a bedside commode for the client to use.
    b. Stay with the client while providing privacy.
    c. Make sure the call light is in reach to signal completion.
    d. Gather supplies to collect a stool sample for the laboratory.

Answer 11

ANS: B
The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone near- by when they have their rst postoperative bowel movement. Making sure the call light is within reach is an im- portant nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation.

Question 12

13. An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavi- ly. Which action should the nurse take rst?
    a. Send a blood sample for a type and crossmatch.
    b. Insert a large intravenous line for uid resuscitation.
    c. Obtain the heart rate and blood pressure.
    d. Assess and maintain a patent airway.

Answer 12

ANS: D
All of the options are important nursing actions in the care of a trauma client. However, airway always comes rst. The client must have a patent airway, or other interventions will not be helpful.

Question 13

14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?
    a. Administer intravenous opioid medications.
    b. Position the client with knees to chest.
    c. Insert a nasogastric tube for decompression.
    d. Assess the client’s bowel sounds.

Answer 13

ANS: D
A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notied of the change in his or her condi- tion. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

Question 14

15. A nurse assesses a client who is prescribed 5- uorouracil (5-FU) chemotherapy intravenously for the treat- ment of colon cancer. Which assessment nding should alert the nurse to contact the health care provider?
    a. White blood cell (WBC) count of 1500/mm3
    b. Fatigue
    c. Nausea and diarrhea
    d. Mucositis and oral ulcers

Answer 14

ANS: A
Common side eects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral
neuropathy. However, the client’s WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notied. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment ndings are consistent with common side eects of 5-FU that would not need to be reported immediately.

Question 15

16. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, “The stool in my pouch is still liquid.” How should the nurse respond?
    a. “The stool will always be liquid with this type of colostomy.”
    b. “Eating additional ber will bulk up your stool and decrease diarrhea.”
    c. “Your stool will become rmer over the next couple of weeks.”
    d. “This is abnormal. I will contact your health care provider.”

Answer 15

ANS: A
The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This nding is not abnormal. Liquid stool from an ascending colostomy will not become rmer with the addition of ber to the client’s diet or with the passage of time.

Question 16

17. A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, “I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?” How should the nurse respond?
    a. “This drug is still in the research phase and is not available for public use yet.”
    b. “Unfortunately, lubiprostone is approved only for use in women.”
    c. “Lubiprostone works well. I will recommend this prescription to your provider.”
    d. “This drug should not be used with bulk-forming laxatives.”

Answer 16

ANS: B
Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the in- testines to increase uid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men.

Question 17

18. A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse in- clude in this client’s plan of care?

a. “You may experience nausea and vomiting for the rst few weeks.”
b. “Carbonated beverages can help decrease acid re ux from anastomosis sites.”
c. “Take a stool softener to promote softer stools for ease of defecation.”
d. “You may return to your normal workout schedule, including weight lifting.”

Answer 17

ANS: C
Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consis- tency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

Question 18

19. A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client?
    a. “Eat low- ber and low-residual foods.”
    b. “White rice and bread are easier to digest.”
    c. “Add vegetables such as broccoli and cauli ower to your new diet.”
    d. “Foods high in animal fat help to protect the intestinal mucosa.”

Answer 18

ANS: C
The client should be taught to modify his or her diet to decrease animal fat and rened carbohydrates. The client should also increase high-ber foods and Brassica vegetables, including broccoli and cauliower, which help to protect the intestinal mucosa from colon cancer.

Question 19

20. A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection.
    b. Change the ostomy pouch and wafer every morning.
    c. Allow the pouch to completely ll with stool prior to emptying it.
    d. Use surgical tape to secure the pouch and prevent leakage.

Answer 19

ANS: A
The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morn- ing. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

Question 20

21. A nurse cares for a client who has a family history of colon cancer. The client states, “My father and my brother had colon cancer. What is the chance that I will get cancer?” How should the nurse respond?
    a. “If you eat a low-fat and low- ber diet, your chances decrease signi cantly.”
    b. “You are safe. This is an autosomal dominant disorder that skips generations.”
    c. “Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer.”
    d. “You should have a colonoscopy more frequently to identify abnormal polyps early.”

Answer 20

ANS: D
The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancer- ous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client’s diet, preemptive chemotherapy, and removal of polyps will decrease the client’s risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-ber diet.

Question 21

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.)
   a. Performs hand hygiene and positions the client in high-Fowler’s position, with pillows behind the head and shoulders
   b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the uid aspirated from the tube
   d. Secures the NG tube by taping it to the client’s nose and pinning the end to the pillowcase
   e. Connects the NG tube to intermittent medium suction with an anti-re ux valve on the air vent

Answer 21

ANS: A, C, E
The client’s head should be exed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client’s gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

Question 22

23. After teaching a client who is recovering from a colon resection, the nurse assesses the client’s understand- ing. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)
    a. “I must change the ostomy appliance daily and as needed.”
    b. “I will use warm water and a soft washcloth to clean around the stoma.”
    c. “I might start bicycling and swimming again once my incision has healed.”
    d. “Cutting the ange will help it t snugly around the stoma to avoid skin breakdown.” e. “I will check the stoma regularly to make sure that it stays a deep red color.”
    f. “I must avoid dairy products to reduce gas and odor in the pouch.”

Answer 22

ANS: B, C, D
The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appli- ance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be se- cured to the client’s skin. The client should avoid using soap to clean around the stoma because it might pre- vent eective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth in- stead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The ange should be cut to t snugly around the stoma to reduce contact between excretions and the client’s skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

Question 23

24. A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client’s assessment? (Select all that apply.)
    a. “Which food types cause an exacerbation of symptoms?”
    b. “Where is your pain and what does it feel like?”
    c. “Have you lost a signi cant amount of weight lately?”
    d. “Are your stools soft, watery, and black in color?”
    e. “Do you experience nausea associated with defecation?”

Answer 23

ANS: A, B, E
The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client’s pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

Question 24

25. A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client’s plan of care? (Select all that apply.)
    a. Encouraging ambulation three times a day
    b. Encouraging normal urination
    c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support
    e. Forcibly reducing the hernia

Answer 24

ANS: A, B, D
Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoper- ative care.

Question 25

. 26A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment nd- ings should the nurse correlate with this diagnosis? (Select all that apply.)

a. Serum potassium of 2.8 mEq/L
b. Loss of 15 pounds without dieting
c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds
e. Serum sodium of 121 mEq/L

Answer 25

ANS: A, C, E
Small bowel obstructions often lead to severe uid and electrolyte imbalances. The client is hypokalemic (nor- mal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

Question 26

27. A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.)
    a. Indirect inguinal hernia – An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac
    b. Femoral hernia – A peritoneum sac pushes downward and may descend into the scrotum
    c. Direct inguinal hernia – A peritoneum sac passes through a weak point in the abdominal wall
    d. Ventral hernia – Results from inadequate healing of an incision
    e. Incarcerated hernia – Contents of the hernia sac cannot be reduced back into the abdominal cavity

Answer 26

ANS: C, D, E
A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect in-

Question 27

7. A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client’s plan of care? (Select all that apply.)
   a. Using premoistened disposable wipes for perineal care
   b. Turning the client from right to left every 2 hours
   c. Using an antibacterial soap to clean after each stool
   d. Applying a barrier cream to the skin after cleaning
   e. Keeping broken skin areas open to air to promote healing

Answer 27

ANS: A, B, D
The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept o the aected area, and open skin areas should be cov- ered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

Question 28

29. A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.)
    a. Assess for proper placement of the tube every 4 hours.
    b. Flush the tube with water every hour to ensure patency.
    c. Secure the NG tube to the client’s upper lip.
    d. Disconnect suction when auscultating bowel peristalsis.
    e. Monitor the client’s skin around the tube site for irritation.

Answer 28

ANS: A, D, E
The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client’s nose. When auscultating bow- el sounds for peristalsis, the nurse should disconnect suction.

Question 29

3. After teaching a client who has a femoral hernia, the nurse assesses the client’s understanding. Which state- ment indicates the client needs additional teaching related to the proper use of a truss?
   a. “I will put on the truss before I go to bed each night.”
   b. “I’ll put some powder under the truss to avoid skin irritation.”
   c. “The truss will help my hernia because I can’t have surgery.”
   d. “If I have abdominal pain, I’ll let my health care provider know right away.”

Answer 29

ANS: A
The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.