Exam 2 Flashcards
steps of ostomy care for a patient
Remove and dispose of the used ostomy pouch. Assess the integrity of the stoma and peristomal skin. Cleanse the area surrounding the stoma. Measure the stoma. Prepare the new pouch to fit stoma. Apply the new pouch.
Which assessment cues would alert the nurse that the patient with diarrhea is declining?
Has two more episodes of liquid stools
Having two more episodes of liquid stools indicates the patient is declining.
Exhibits dry mucous membranes
Developing signs of dehydration (exhibiting dry mucous membranes) indicates the patient is declining.
Exhibits poor skin turgor
Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating?
Moist, blue
A moist, blue stoma indicates the patient is declining/deteriorating, and the health care provider needs to be notified.
Which action would the nurse take for a patient with a newly formed bowel diversion?
Perform stoma care him- or herself.
The nurse would not delegate this skill if the stoma is new or complications are present; thus, the nurse would perform stoma care because the patient has a new bowel diversion.
Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient’s bowel elimination needs?
Record intake and output for a frail older adult.
The nurse can delegate recording intake and output to the UAP.
Which action would the nurse take for a patient whose ostomy stoma is speckled white?
Notify the health care provider.
The health care provider is notified because the findings indicate the patient has probably developed a fungal infection.
Which action would the nurse take if there are concerns during administration of the enema?
If the patient cannot hold the enema solution, place the patient on a bedpan.
If the patient cannot retain the enema, place the patient on a bedpan.
Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent?
“I should take the medicine for no more than 72 hours.”
This statement indicates patient understanding. It is recommended that a patient limit use of opioid antidiarrheal drugs to 48 to 72 hours.
For which constipated patient would the nurse administer a laxative?
One who is allergic to opiates
Laxatives are not opiate-based drugs; therefore the nurse would administer the laxative to this patient.
Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant?
Senna
The nurse would observe senna on the MAR. Senna is a type of stimulant cathartic laxative.
For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance?
Gastric lavage
A large-bore nasogastric tube allows the stomach to be irrigated with fluids to flush out poisons and blood.
Which action would the nurse take first when there is no movement of fluid in the patient’s nasogastric tube and the patient’s abdomen is becoming distended?
Irrigate the tube with normal saline.
The nurse would irrigate the tube with normal saline first when there is no movement of fluid in the nasogastric tube and the patient’s abdomen is becoming distended.
Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health?
“Because I am 50, I need to have a fecal occult blood test every year.”
This statement reflects the recommended screening guidelines for fecal occult blood testing and indicates successful teaching.
“Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now.”
Sigmoidoscopy and colonoscopy screening for colorectal polyps and early signs of cancer begins at age 45 to 50 for most people. This statement indicates successful teaching.
Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health?
Walking stimulates intestinal muscle contraction.
The nurse would include this information because aerobic exercise, like walking, stimulates contraction of intestinal muscles.
Usually 6 to 8 glasses of fluid should be consumed per day.
The nurse would include this information because the patient needs 6 to 8 glasses of fluid to keep feces soft.
Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated?
Monitor intake and output.
The nurse would monitor intake and output for a patient with diarrhea and dehydration.
Weigh daily.
The nurse would weigh the patient daily, especially because dehydration is developing.
Assess skin turgor.
The nurse would assess skin turgor, especially because dehydration is developing.
Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating?
Heart rate drops to 56 beats/min
A heart rate below 60 beats/min indicates the patient is declining/deteriorating.
Blood pressure elevates from 120/60 to 142/66 mm Hg
Blood pressure elevation by 20 to 40 mm Hg (120 to 142 mm Hg) indicates the patient is declining/deteriorating.
Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy?
Measure the stoma.
Careful measurement of the stoma is necessary to prevent injury to the stoma or surrounding skin.
Assess the pouch seal.
The pouch is assessed to make sure the seal is secure to prevent leakage and potential skin breakdown.
Gently wash the stoma and peristomal area with water.
It is important to wash the stoma and surrounding area to prevent skin irritation and to enhance adherence of the pouch.
Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient?
Assisting the patient to the bathroom
Because the patient can walk to the bathroom, the nurse would assist the patient to the bathroom.
Ensuring that nonskid shoes/socks are in place
For safety, the patient would wear nonskid footwear to prevent falls.
Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration?
Fever
Temperature (fever) occurs with aspiration.
Congested lung sounds
Lung congestion or congested lung sounds occur with aspiration.
Shortness of breath
Dyspnea, or shortness of breath, occurs with aspiration.
After how many enemas would the nurse notify the health care provider when the patient’s bowel return for cleansing enemas is still brown? Record your answer as a whole number. __ enemas
3
Which processes are functions of the large intestine?
Secretion
Secretion is a function of the large intestine. The large intestine secretes bicarbonate in exchange for chloride.
Elimination
Elimination is a function of the large intestine. The large intestine eliminates potassium, feces, and flatus.
Absorption
Absorption is a function of the large intestine. The large intestine absorbs water continually from chyme, converting it to solid feces/stool.
The gastrointestinal tract has which function?
Absorption of nutrients and fluids
The gastrointestinal tract absorbs nutrients and fluids.
Which structure is the primary organ that aids in defecation?
Large intestine
The large intestine is the principal organ of bowel elimination and aids in defecation.
Which function does defecation serve?
Expels feces
Defecation expels feces/stool from the body. The ultimate function of the large intestine and the final act of digestion to produce feces and expel it from the body. In nursing this is called a bowel movement or stool.
Which information is accurate regarding the structure and function of the esophagus?
Connects the pharynx to the stomach
The esophagus connects the pharynx to the stomach.
Is a collapsible tube that transports a food bolus
The esophagus is a collapsible tube that transports a food bolus.
Which factors can affect a patient’s bowel movements?
Dietary intake
Dietary intake can affect a person’s bowel movements by affecting the consistency (hard, soft) of stools.
Medication use
Medication use can affect a person’s bowel movements by either causing diarrhea or constipation.
Pain
Pain can affect a person’s bowel movements by suppressing the urge to defecate.
Recent surgery
Recent surgery can affect a person’s bowel movements by slowing peristalsis.
Which information regarding the frequency of bowel movements is accurate?
Varies from person to person
The frequency of defecation, along with the characteristics of feces, will vary and differs from person to person.
Which amount of fluid (in ounces) is recommended for an adult to maintain healthy bowel elimination?
64
Which question addresses psychological factors that can affect a patient’s bowel elimination?
Is the patient experiencing stress?
Stress is a psychological condition that can affect elimination. Stress can lead to diarrhea.
Which medications would increase the patient’s risk for constipation?
Opioids
Opioids increase the likelihood of constipation.
Correct
Antacids
Antacids increase the likelihood of constipation.
Iron supplements
Iron supplements increase the likelihood of constipation.
Which type of intestinal movement would a patient with a paralytic ileus have?
None
If the intestines are manipulated during surgery, intestinal movement stops (none), causing a paralytic ileus.
Which information would the nurse share with a patient who has a loop colostomy?
“After your bowels heal, they will be reattached.”
With a temporary colostomy, the bowels will be reattached after healing occurs.
Which type of procedure creates no stoma on the patient‘s abdomen?
Ileoanal pouch
An ileoanal pouch is a reservoir in the abdomen that collects stool. It does not have a stoma because it is connected to the anus.
Which characteristics are typical of a loop colostomy?
Has one stoma with two openings
This is a characteristic of a loop colostomy. A loop colostomy has one stoma with two openings.
Correct
Has mucus drain from the distal end of the stoma
This is a characteristic of a loop colostomy. The distal end discharges mucus in a loop colostomy.
Correct
Has stool drain from the proximal end of the stoma
This is a characteristic of a loop colostomy. Stool drains from the proximal end in a loop colostomy.
Is usually created in an emergency
This is a characteristic of a loop colostomy. A loop colostomy is usually created in an emergency.
Stool drainage from a sigmoid colostomy has which characteristics?
Well-formed
Well-formed stools are indicative of a sigmoid colostomy. The location of the sigmoid colon allows the stool to stay in the intestine longer and has a more normal consistency.
Well-regulated
The stools can be well regulated in a sigmoid colostomy.
Which type of ostomy causes the patient to lose a large amount of water, electrolytes, and digestive enzymes through a stoma?
Ileostomy
The patient with an ileostomy loses a high volume of water, electrolytes, and digestive enzymes through a stoma.
From which area would the nurse observe stool draining in a double-barrel colostomy?
Proximal end
The functional proximal end, closest to the small intestine, drains feces/stool.
Which question would the nurse ask first to obtain information about the patient’s bowel habits?
“Where is your abdominal pain?”
“Do you have any bloating or gas?”
“How many bowel movements do you have a day?”
“What medications do you take on a regular basis?”
“How many bowel movements do you have a day?”
Which assessment technique for the abdomen is performed last to avoid a false finding?
Palpation
Inspection
Auscultation
Patient interview
Palpation
Which assessment findings indicate the patient has hyperactive bowel sounds?
Select all that apply.
Tinkling sound
Rushing sound
Fewer than five sounds per minute
Sounds occur every 5 to 15 seconds
High-pitched sound
Soft gurgling sound
Tinkling sound
Rushing sound
High-pitched sound
The patient’s stool culture will help detect which finding?
Cancer
Intestinal polyps
Abnormal bacteria
Small amounts of blood
Abnormal Bacteria
Which cue is irrelevant for a patient with constipation?
Expels hard, pebble-like stools
Does not like to exercise
Has an abnormal serum creatinine level
Eats low-fiber foods
Has abnormal serum creatinine level
Which cues would the nurse expect to observe in a patient suffering from diarrhea?
Select all that apply.
Hyperactive bowel sounds
Excessive straining to pass stool
Abdominal pain
Continuous leaking of liquid stool
Urgency
Hemorrhoids noted in medical history
Hyperactive bowel sounds
Abdominal Pain
Urgency
Which relevant cues would the nurse share with the health care provider when consulting about a patient who has developed constipation?
Select all that apply.
Bed linens are soiled with stool.
Graphic record shows no stool in 2 days.
Patient strains while trying to have a bowel movement.
Patient reports urgency and abdominal cramping.
Decreased bowel sounds auscultated.
Graphic record shows no stool in 2 days
PT strains while trying to have a bowel movement
Decreased bowel sounds auscultated
Which patient is at risk for developing an impaction?
One who is immobile
One who is lactose intolerant
One who is infected with Clostridium difficile
One who is receiving enteral feedings
One who is immobile
Which cause would the nurse consider if the patient is experiencing flatulence?
Unconsciousness
Loss of nerve sensation
Inability of anal sphincters to work properly
Action of bacteria on chyme
Action of bacteria on chyme
Which question would the nurse ask to gather cues about drug-related issues for bowel elimination?
“Are you using any herbal supplements?”
“Do you have any bloating or gas?”
“When did this start?”
“Where is the pain?”
A
Which finding would the nurse categorize as an expected finding for an abdominal assessment?
Presence of visible peristaltic waves
Nonprotruding midline umbilicus
Asymmetrical abdomen
Ascites
B
Which information would the nurse share with the patient about how blood can be detected in a guaiac test?
A small amount of feces is applied to a special medium for growing microorganisms.
The stool sample is exposed to a special chemical that changes color when blood is present.
Feces is placed on a slide and visualized under a microscope, noting any blood.
Stool is viewed under special lighting, showing reddish streaks if blood is present.
B
Which action by the new nurse while performing an abdominal assessment would cause the charge nurse to intervene?
Auscultates before palpates
Turns off the nasogastric suction while auscultating
Palpates a pulsating midline mass
Communicates with the patient in a matter-of-fact manner
C
Which action would the nurse take when performing an abdominal assessment?
Interviews the patient after the physical assessment
Palpates the area of pain last
Percusses the abdomen routinely
Auscultates with cooled stethoscope
B
Which expected assessment cue would the nurse find upon palpation of the abdomen?
Hard
Rough
Painless
Mass-filled
C
Which diagnostic study would help determine whether there is bleeding in the patient’s stomach?
Barium enema
Lower gastrointestinal (GI) series
Esophagogastroduodenoscopy
Colonoscopy
C
