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
Which cues would be anticipated in a patient with flatulence and bloating?
Select all that apply.
Abdominal tenseness on palpation
Visible peristaltic waves
Feelings of nausea
Reports passing excessive gas through the rectum
Reports of abdominal pressure
A, D, E
Which bowel assessment findings would the nurse report as unexpected?
Select all that apply.
Rebound tenderness present
Active bowel sounds
Steatorrhea
Clay-colored, round stool
Symmetrical abdomen
A,C,D
Which findings would cause the nurse to document “active” bowel sounds?
Select all that apply.
Gurgling
Soft
High-pitched
Sounds every 5 to 15 seconds
Irregular pattern
A, B, D, E
How long would the nurse auscultate the abdomen before documenting no or absent bowel sounds? Record answer as a whole number.
minutes
Use numbers only.
5
Place in the correct order the steps to perform a complete assessment of bowel function.
Auscultation
Inspection
Interview
Palpation
iNTERVIEW
iNSPECTION
AUSCULTATION
PALPATION
Which patient requires immediate medical attention?
A patient with a distended abdomen
A patient with a mass in the abdomen
A patient with hypoactive bowel sounds
A patient with a hard, boardlike abdomen
D
Which cue is irrelevant for a patient with a bowel alteration?
Type of hypertension
Type of bowel sounds
Type of lifestyle
Type of diet
A
The nurse caring for a patient suffering from chronic constipation must be aware of which potential complication?
Incontinence
Dehydration
Clostridium difficile (C. diff) infection
Fecal impaction
D
Which cause is the likely reason a patient on long-term antibiotic therapy is experiencing frequent, foul-smelling diarrhea?
Foodborne pathogens
Excessive laxative use
Clostridium difficile
Food intolerances
C
Which location in the medical record would the nurse check to determine the date of the patient’s last bowel movement?
Vital signs graph
Graphic chart
Laboratory results
Medical history
B
Which characteristic describes bowel sounds auscultated in a patient with constipation?
Fewer than five per minute
Tinkling
Soft, gurgling
Rushing
A
Which factors could be potential sources of a patient’s flatus?
Select all that apply.
History of recent abdominal surgery
Use of bran for fiber
Increased activity level
Presence of milk intolerance
Current diet
A,B,D,E
The nurse understands that patients may experience diarrhea due to which causes?
Select all that apply.
Psychological stress
Inadequate liquid intake
Antibiotic use
Enteral nutrition
Barium enema
A, C, D
Which cues suggest bowel alteration due to impaction?
Select all that apply.
Has not had a bowel movement in 4 days
Has bacteria in stool specimen
Has hyperactive bowel sounds
Has palpable hard fecal mass
Has continuous leakage of liquid stool
A, D, E
Which patients are immediate concerns?
Select all that apply.
A teenager with absent bowel sounds
A young adult who ate onions and beans
A middle-aged adult with bowel incontinence
A young child with diarrhea who develops dehydration
An older adult who is positive for Clostridium difficile (C. diff) stool culture
A,D,E
Match each bowel alteration to its cause.
Prolonged constipation
Select an answer
Paralyzed rectum muscles
Select an answer
Slowed peristalsis
Select an answer
Increased peristalsis
Select an answer
Options are:
Impaction
Incontinence
Diarrhea
Constipation
Prolonged Constiption: Impaction
Paralyzed Rectum Muscles: Incontnence
Slowed Peristalsis: Constipation
Increased Peristalsis: Diarrhea
Which cues support the hypothesis of Constipation for a patient?
Select all that apply.
Limited mobility
Receives narcotic pain medication
Decreased fluid intake
Female sex
Hyperactive bowel sounds
Limited mobility
Limited mobility is a cue for Constipation.
Receives narcotic pain medication
Receiving narcotic pain medication is a cue for Constipation.
Decreased fluid intake
A decreased fluid intake is a cue for Constipation.
Which interpretation would the nurse make about a patient who says, “I only had one bowel movement this week”?
This is abnormal.
The patient is constipated.
This may be an expected or unexpected finding.
The patient has a fecal impaction.
This may be an expected or unexpected finding.
This is the only interpretation the nurse can make about this patient at this time. Individual “normals” must be determined before making a judgment on whether it is an expected or unexpected finding.
Which cues would prompt the nurse to develop a hypothesis of Dehydration for a patient?
Select all that apply.
Numerous semiliquid stools
Output more than intake
Dry mouth
Abdominal stoma
No bowel movement in several days
Numerous semiliquid stools
Numerous semiliquid stools is a cue for Dehydration from a loss of fluids.
Output more than intake
Output more than intake is a cue for loss of fluid leading to Dehydration.
Dry mouth
Dry mucous membranes (mouth) is a cue for Dehydration.
Which overall elimination goal is appropriate for a patient with a decrease in the frequency of bowel movements?
Prevent diarrhea.
Maintain normal defecation.
Enhance body image.
Relieve constipation.
Relieve constipation.
The overall goal is to relieve constipation because the patient is experiencing a decrease in the frequency of bowel movements.
Which hypothesis would the nurse address first for a patient having continuous seepage of liquid stool?
Impaired Ability to Manage Stoma Care
Constipation
Fecal Impaction
Impaired Self-Toileting
Fecal Impaction
Fecal Impaction is the hypothesis to address first. Seeping liquid stool is a cue for Fecal Impaction.
Which solution would the nurse consider for a patient with constipation who is on bed rest?
Ambulation
Consultation with a wound, ostomy, and continence nurse (WOCN)
Consumption of foods that produce gas
Patient education about fluid needs
Patient education about fluid needs
The nurse would consider patient education about fluid needs for constipation.
Which outcome would the nurse include for a patient with a hypothesis of reluctant to care for stoma?
Patient will be able to wear a pouch only when in public.
Patient will state one good aspect about body.
Patient will contribute to self-care after toileting.
Patient will assist with ileostomy care daily.
Patient will assist with ileostomy care daily.
Patient will assist with ileostomy care daily is related to the hypotheses of reluctant to care for stoma and indicates the hypothesis has been resolved in measurable terms.
Which SMART outcomes would the nurse add to a plan of care for a patient with dehydration?
Select all that apply.
Patient will have moist mucous membranes.
Patient will have supple skin turgor within 48 hours.
Patient will have good urine output.
Patient will have a moist mouth throughout hospital stay.
Patient will have adequate fluid intake at breakfast.
Patient will have supple skin turgor within 48 hours.
Having supple skin turgor within 48 hours is a SMART outcome because it is specific, realistic, measurable, patient-centered, attainable, and has a time frame.
Patient will have a moist mouth throughout hospital stay.
Having a moist mouth throughout hospital stay meets all the requirements for a SMART outcome because it is specific, realistic, measurable, patient-centered, attainable, and has a time frame.
Which cue would prompt the nurse to select a hypothesis of Bowel Incontinence for a patient?
Abdominal distention noted on inspection
No stool in 3 days per patient report
Intermittent soiling from soft feces
Hypoactive bowel sounds
C
Which hypothesis would the nurse develop for a patient who states, “I can’t stand to look at the stoma or this colostomy bag”?
Disturbed Body Image
Impaired Self-Toileting
Risk for Impaired Skin Integrity
Diarrhea
A
Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Diarrhea?
Quick transit time reducing water absorption
Engorged rectal veins
Neurologic impairment to control bowels
Exposed skin to stool enzymes
A
The nurse would consider which pathophysiologic factor when caring for a patient with dementia whose bed linens are soiled several times a day?
Altered mobility issues
Impaired neurologic status
Impaired muscular functioning
Altered gastrointestinal transit time
B
Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools?
Fecal Impaction
Bowel Incontinence
Diarrhea
Constipation
C
The nurse would develop a hypothesis of Risk for Impaired Skin Integrity for which patient?
A patient with an ostomy created from the ileum
A patient whose intake is less than output
A patient whose abdomen is distended
A patient with active bowel sounds
A
Which patient situation would the nurse prioritize as the most critical?
Choking on food, closing airway
Having hypoactive bowel sounds
Experiencing severe flatulence
Passing excessive watery stools
A
The nurse recognizes that the outcome of “Patient will pass soft stools daily during rehabilitation” directly applies to which hypothesis?
Constipation
Dehydration
Impaired Self-Toileting
Risk for Impaired Skin Integrity
A
Which member of the multidisciplinary team would the nurse include in caring for a patient who has impaired manual dexterity for toileting?
Nutritionist/dietitian
Physical therapist
Mental health professional
Wound, ostomy, and continence nurse
B
Which solution would the nurse consider for a patient with flatulence who is in traction?
Consultation with a mental health professional
Institution of isolation precautions
Ambulation of patient
Avoidance of foods that produce gas
D
Which overall goal would the nurse focus on while caring for a patient with severe diarrhea?
Maintain normal elimination patterns.
Prevent dehydration.
Relieve hard stools.
Avert fecal impaction.
B
Which overall goal would the nurse select for a patient who has occasional fecal incontinence?
Maintain intact skin.
Promote hydration.
Prevent constipation.
Relieve flatus.
A
Which elimination outcome indicates the nurse has considered the physical abilities of the patient in a coma?
The patient will assist with self-toileting this afternoon.
The patient will walk to the bathroom with assistance after breakfast.
The patient will have intact skin after each bowel movement.
The patient will report passage of a soft stool this morning.
C
Which hypothesis is associated with the patient outcome “Patient will defecate without burning or pain while hospitalized”?
Constipation
Fecal Impaction
Hemorrhoid
Bowel Incontinence
C
Which cues would prompt the nurse to select a hypothesis of Risk for Constipation for a patient?
Select all that apply.
Is on a high-fiber diet
Has increased intestinal motility
Has poor fluid intake
Is on complete bed rest
Has an ileostomy
C,D
Which cues would prompt the nurse to develop the hypothesis of Impaired Self-Toileting for a patient?
Select all that apply.
Weakness in left leg
Paralysis of the lower extremities
Hemiparesis on the right side
Cramping in the abdomen
Bloated stomach
A,B,C
Which cues support the nurse formulating a hypothesis of Constipation for a patient?
Select all that apply.
“My stools are like little hard stones.”
“I sometimes lose control of my bowels.”
“I watch a lot of movies for entertainment.”
“My wife makes me eat a bran muffin every morning.”
“I frequently take an opioid medication for my back pain.”
A,C,E
Which multidisciplinary team members would the nurse likely collaborate with when caring for a patient who has constipation from a low-fiber diet and pain medications and needs assistance with self-toileting from hip surgery?
Select all that apply.
Health care provider
Nutritionist/dietitian
Physical therapist
Mental health professional
Wound, ostomy, and continence nurse
A,B,C
Which goals would the nurse select for a patient with frequent watery stools?
Select all that apply.
Patient will pass soft stool within 48 hours.
Patient will defecate formed stool within 24 hours of treatment.
Patient will have two fewer episodes of diarrhea within 24 hours.
Patient will assist with self-care after toileting within 2 days.
Patient will consume less than 1000 mL of fluid daily.
A,B,C
Which solutions would the nurse select for a patient with diarrhea caused by Clostridium difficile (C. diff)?
Select all that apply.
Laxative administration
Fluid measures
Fecal management system
Isolation precautions
Intake and output monitoring
B.D.E
Which hypotheses relate to the outcome of patient will pass soft, formed stools?
Select all that apply.
Constipation
Diarrhea
Fecal Impaction
Risk for Impaired Skin Integrity
Impaired Ability to Manage Stoma Care
A,B,C
The nurse is carring for a patient with malabsorption syndrome. Which change in bowel elimination is the patient likely to report?
Pale stools
Oily stools
The nurse provides education for a group of community members about colorectal cancer. Which warning sign of cancer would be included?
Rectal Bleeding
Change in bowel habits
What is the recommended daily fluid intake for men?
3.7
Which type of laxative acts by causing the stool to absorb water and swell?
Bulk forming
A parent tells the nurse, “My infant who is breastfed passes stools an average of 5 times per day.” Which response would the nurse provide to the parent?
“This is a normal finding for an infant.”
The nurse assesses a 55 year old patient as part of a routine physical. Based on which criterion would the nurse instruct the patient to obtain a stool specimens for guaiac fecal occult blood testing (gFOBT)?
If the patient is experiencing no bowel elimination problems
The nurse is caring for a patient who has a colostomy. When assessing the stoma, which color indicates that the stoma is healthy?
Pink
Red
Which cause would the nurse suspect when mucus is noted in a patient’s feces?
Intestinal infection
A pateint with renal dysfunction experiences constipation. Which medication would the nurse avoid in this patient when managing the constipation?
Magnesium hydroxide
A patient experiences chronic constipation but has no other symptoms, which medication would the nurse anticipate the health care provider to prescribe to provide relief for the condition
Polycarbophil
Which constituent of feces is normal?
Bile pigment
Dead bacteria
Cells lining the intestinal mucosa
Which complication may result from a patient who regularly ingests castor oil to relieve constipation?
Abdominal cramping
Fluid and electrolyte imbalance
Which sign magnifest in infants and young children who are dehydrated?
High Fever
Sunken eyes
Dry eyes when crying
Listlessness or irritability
A patient presents with abdominal discomfort and the nurse auscultates 40 bowel sounds in 1 min. Which pattern of bowel sounds does the nurse document
Hyper active
The nurse observes teh presence of tympanic note when percussing the abdomen of a PT. Which causes would the nurse suspect?
Gas
When sybstance indicates an abnornality when the nurse analyzes the characteristics of a pt’s feces?
Excess fat
Blood
Mucus
A PT reports passing black and tarry stools. The nurse identifies that the patient should be evaluated for which condition
Iron Ingestion
Gastrointestinal Bleeding
An older adult african american PT reports a change in bowel bahits with rectal bleeding and a sense of incomplete bowel evacuation. Which disorder would the nurse suspect in this PT?
Colon Cancer
Which substance may cause complications for a patient who has kidney dysfunction?
Magnesium Hydroxide
A PT reports passing narrow pencil-shaped stools over the past few days. Which cause would the nurse suspect for the assessment finding?
Obstruction
Increased peristalsis
A PT needs a bowel preparation before a procedure. Which medication would the nurse anticipate will be prescribed?
Sodium Phosphate
Which frequesncy of defecation is abnormal for an infant?
No more than 6 times per day
The nurse cares for an infant in the neonatal unit who is being breastfed. How often should the infant pass stools?
6 times per day
A PT has been diagnosed with malabsorption of fat from the intestine. Which appearance with the PTs stools have
Pale and oily
Which findings in a PT’s stool analysis indicates an abnormality?
pus
mucus
Whch number of seconds between consecutive bowel sounds is a normal finding?
Normal is between 5 and 15 seconds
Which action would the nuse take when collecting a guaiac fecal occult blood test (gDOBT)?
Interpret the color of the guaiac paper after 30-60 seconds
A PT is admitted to the emergency department after the ingestion of a poison. Which type of cathartic would the nurse anticipate being prescribed to the PT?
Magnesium citrate
Which assessment finding would cause the nurse to suspect that a PT has a bowel obstruction
Cramping; absence of bowel movements
Which information does the nurse consider when caring for PTs of varying ages with disorders of bowel elimination?
The ability to controle defecation is absent until 2-3 years of age.
On auscultating the abdomen of a PT with a stethoscope, the nurse hears high-pitched and hyperactive bowel sounds. Which condition corresponds with the assessment findings?
Small intestine obstruction
A PT is scheduled for a plain film x-ray of the kidney, ureter, and bladder. Which preparation will be included on the PT’s treatment plan
No Preparation required
Which tube is appropriated as an intervention for bleeding esophageal varices
Sengstaken-Blakemore
When comparing the nasogastric tube used for gastric decompression, the nurse recognizes which specific purpose of the Salem Sump?
Allow for stomach decompression and provide an air vent.
A PT tells the nurse “I have been using a laxative for so long that it is nearly impossible to defecate without it.” Which lacative would cause this type of dependence?
Senna
