Elimination Flashcards
A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next?
a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.
b. Percuss all quadrants of the abdomen in a systemic clockwise manner to identify masses, fluid, or air in the abdomen.
c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort.
d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.
a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.
The sequence for abdominal assessment proceeds from inspection, auscultation, precussion, and then palpation.
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction?
a. Elevate the head of the bed 30 degrees and reposition the rectal tube.
b. Place the patient in supine position and modify the amount of solution.
c. Lower the solution container and check the temperature and flow rate.
d. Remove the rectal tube and notify the primary care provider.
c. Lower the solution container and check the temperature and flow rate.
if solution is too cold or the flow rate too fast, sever cramping may occur.
A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply.
a. A patient diagnosed with peritonitis
b. A patient who is on prolonged bedrest
c. A patient who has diarrhea
d. A patient who has gastroenteritis
e. A patient who has an early bowel obstruction
f. A patient who has paralytic ileus caused by surgery
a. A patient diagnosed with peritontitis
b. A patient who in on prolonged bedrest
f. A patient who has paralytic ileus caused by surgery.
A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply.
a. A patient who is taking narcotics for pain
b. A patient who is taking metformin for type 2 diabetes mellitus
c. A patient who is taking diuretics
d. A patient who is dehydrated
e. A patient who is taking amoxicillin for an infection
f. A patient taking over-the-counter antacids
b. A patient who is taking metformin for type 2 diabetes mellitus
e. A patient who is taking amoxicillin for an infection
f. A patient taking over-the-counter antacids
A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient?
a. The nurse administers a large volume of solution (500 to 1,000 mL)
b. The nurse mixes milk and molasses in equal parts for an enema
c. The nurse instructs the patient to retain the enema for at least 30 minutes
d. The nurse administers the enema while the patient is sitting on the toilet
c. The nurse instructs the patient to retain the enema for at least 30 minutes
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.
a. “When you inspect the stoma, it should be dark purple-blue.”
b. “The size of the stoma will stabilize within 2 weeks.”
c. “Keep the skin around the stoma site clean and moist.”
d. “The stool from an ileostomy is normally liquid.”
e. “You should eat dark-green vegetables to control the odor of the stool.”
f. “You may have a tendency to develop food blockages.”
d. “The stool from an ileostomy is normally liquid.”
e. “You should eat dark-green vegetables to control the odor of the stool.”
f. “You may have a tendency to develop food blockages.”
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
a. Have the patient follow a low-fiber diet several days before the test.
b. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1.
c. Prepare the patient for the use of general anesthesia during the test.
d. Explain that barium contrast mixture will be given to drink before the test.
a. Have the patient follow a low-fiber diet several days before the test.
A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse’s next action?
a. Reassure the patient that this is a normal reaction to the procedure.
b. Stop the procedure, prepare to administer CPR, and notify the primary care provider.
c. Stop the procedure, assess vital signs, and notify the primary care provider.
d. Stop the procedure, wait 5 minutes, and then resume the procedure.
c. Stop the procedure, assess vital signs, and notify the primary care provider.
A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed?
A. c, b, d, a
B. d, c, a, b
C. a, b, d, c
D. b, a, d, c
D. b, a, d, c
A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply.
a. Draw up 30 mL of saline solution into the syringe.
b. Unclamp the suction tubing near the connection site to instill solution.
c. Place the tip of the syringe in the tube to gently insert saline solution.
d. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
e. After instilling irrigant, hold the end of the NG tube over an irrigation tray.
f. Observe for return flow of NG drainage into an available container.
a. Draw up 30 mL of saline solution into the syringe.
c. Place the tip of the syringe in the tube to gently insert saline solution.
e. After instilling irrigant, hold the end of the NG tube over an irrigation tray.
f. Observe for return flow of NG drainage into an available container.
The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.
A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention?
a. Using a diet that is low in bulk.
b. Decreasing fluid intake to 1,000 mL
c. Adminstering an enema once a day to stimulate peristalsis
d. Monitoring bowel movements
d. Monitoring bowel movements
A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient?
a. Incontinence
b. Constipation
c. Electrolyte imbalances
d. Infection
a. Incontinence
The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence.
For which patient would a nurse expect the primary care provider to order colostomy irrigation?
a. A patient with IBS.
b. A patient with a left-sided end colostomy in the sigmoid colon
c. A patient with post-radiation damage to the bowel
d. A patient with Chron’s disease
b. A patient with a left-sided end colostomy in the sigmoid colon
Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn’s disease
A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse’s first action in this situation?
a. Reassure the patient that this is a normal finding with a new ostomy.
b. Notify the primary care provider that the stoma is prolapsed.
c. Have the patient rest for 30 minutes to see if the prolapse resolves.
d. Remove the appliance and redo the procedure using a larger appliance.
c. Have the patient rest for 30 minutes to see if the prolapse resolves.
If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient?
A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient?
a. A saline osmotic laxative
b. A bulk-forming laxative
c. Methylcellulose
d. A stool softener
a. A saline osmotic laxative
Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.
