Fundamental Skills And Concepts For Nurses Ch 30

Question 1

1. The nurse has assessed that a patient’s stool has changed from
   brown to dark black and sticky. The nurse suspects:
   a. blockage of the bile duct.
   b. blockage of the pancreatic duct.
   c. recent excessive intake of milk products.
   d. presence of occult blood.

Answer 1

D. Presence of occult blood

Question 2

2. The nurse has documented that a patient has had two episodes of
   steatorrhea, which means that the character of the stool is:
   a. hard and clay colored.
   b. frothy and foul smelling.
   c. very liquid and streaked with blood.
   d. soft and filled with mucus

Answer 2

B. Frothy and foul smelling

Question 3

3. The nurse should plan interventions to combat constipation in a patient:
   a. being treated for diabetes mellitus.
   b. who has a routine order for Metamucil.
   c. who just completed barium studies of the bowel.
   d. with orders to ambulate with assistance

Answer 3

c. who just completed barium studies of the bowel.

Question 4

4. An older adult patient who routinely takes the bulk forming laxative psyllium (Metamucil) is counseled by the home health nurse that in order to prevent constipation and possible fecal impaction, this patient should be sure to take:
   a. extra vitamin C.
   b. a fat-soluble vitamin.
   c. the medication with a large amount of fluid.
   d. an over the counter antacid

Answer 4

C. The medication with a large amount of fluid.

Question 5

5. A patient calls the nurse at the health clinic and reports that since his trip to Mexico, he has been experiencing diarrhea. The nurse suggests he try the antidiarrheal drug:
   a. docusate sodium (Colace).
   b. loperamide (Imodium).
   c. polycarbophil (FiberCon).
   d. senna (Senokot).

Answer 5

B. loperamide (Imodium)

Question 6

6. An older adult resident in a long-term care facility has experienced constant diarrhea for 3 days and is now exhibiting signs and symptoms of dehydration. The nurse initiates an intervention to offer small
   amounts of frequently.
   a. a cola beverage
   b. ginger ale
   c. Gatorade
   d. Kool-Aid

Answer 6

C. Gatorade

Question 7

7. A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the
   patient to eat:
   a. yogurt.
   b. raisins.
   c. gelatin fruit flavored dessert (eg, Jell O).
   d. poultry

Answer 7

A. Yogurt

Question 8

8. The nurse caring for a patient with lactose intolerance would
   anticipate the need to offer interventions for:
   a. diarrhea.
   b. steatorrhea.
   c. constipation.
   d. hemorrhoid discomfort

Answer 8

A. diarrhea

Question 9

9. A nurse has performed abdominal assessments on four patients. After
   reviewing the findings, the nurse is least concerned about problems with
   bowel elimination for the patient with:
   a. abdomen nondistended, firm, with hypoactive bowel sounds in all four
   quadrants.
   b. abdomen nondistended, soft, with active bowel sounds in all four
   quadrants.
   c. abdomen distended, firm, with hypoactive bowel sounds in all four
   quadrants.
   d. abdomen distended, soft, with hyperactive bowel sounds in all four quadrants.

Answer 9

B. abdomen nondistended, soft, with active bowel sounds in all four
quadrants

Question 10

10. A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how
    many days?
    a. 5
    b. 3
    c. 2
    d. 1

Answer 10

B. 3

Question 11

11. A patient has just completed a series of upper gastrointestinal tract
    radiographs that involved the use of barium as a contrast agent. Which
    measure will this patient need to help excrete the barium?
    a. Diuretics and fluid restriction to 1.5 L
    b. Diuretics and fluid intake increased to 3.5 L
    c. Laxatives and fluid restriction to 1.5 L
    d. Laxatives and fluid intake increased to 3.5 L

Answer 11

D. Laxatives are fluid intake increased to 3.5 L

Question 12

An ambulatory clinic patient telephones to report diarrhea and to

ask for advice on medication to manage it. The best response by
the nurse is, “Do not use antidiarrheal medication for longer than:
a. 24 hours without calling back for an appointment.”
b. 48 hours without calling back for an appointment.”
c. 72 hours without calling back for an appointment.”
d. 96 hours without calling back for an appointment.”

Answer 12

B. 48 hours without calling back for an appointment”

Question 13

13. There is an order to administer a cleansing enema to an adult patient
    before bowel surgery. The nurse will fill the enema bag with how many
    milliliters of fluid for this procedure?
    a. 500 to 1000 mL
    b. 300 to 500 mL
    c. 200 to 300 mL
    d. 50 to 150 mL

Answer 13

A. 500 to 1000 mL

Question 14

4. A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?
   a. 10 minutes
   b. 15 minutes
   c. 20 minutes
   d. 40 minutes

Answer 14

C. 20 minutes

Question 15

15. A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should:
    a. cool the solution to 70° F.
    b. warm the solution in the microwave.
    c. keep the solution at room temperature.
    d. warm the solution to 105° F.

Answer 15

D. Warm the solution to 105° F.

Question 16

16. A patient scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware that no more than three enemas should be given because:
    a. repeated enemas may cause more flatus.
    b. the patient may develop an irritated rectum.
    c. repeated enemas may cause electrolyte imbalance.
    d. the patient may develop severe diarrhea

Answer 16

c. repeated enemas may cause electrolyte imbalance

Question 17

17. A nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient’s:
    a. blood pressure increases from 110/84 to 118/88 mm Hg.
    b. pulse rate decreases from 78 to 52 beats/min.
    c. respiratory rate increases from 16 to 24 breaths/min.
    d. temperature increases from 98.8° F to 99.0° F.

Answer 17

b. pulse rate decreases from 78 to 52 beats/min

Question 18

18. A nurse is reinforcing education with a patient who will begin a bowel training program. An intervention this program does not include is:
    a. regularly scheduled time for toileting.
    b. fluid intake of at least 1500 mL daily.
    c. use of a suppository.
    d. use of an enema

Answer 18

D. Use of an enema

Question 19

19. A nurse is assisting a patient with a new continent ileostomy to
    catheterize the internal reservoir to drain the ileostomy. When the
    catheter meets resistance from the internal valve, the nurse should:
    a. have the patient take a deep breath and apply gentle pressure over the area.
    b. withdraw the catheter and start again with a new one.
    c. ask the patient to bear down and hold her breath.
    d. coat the opening with petroleum jelly or a water soluble lubricant

Answer 19

a. have the patient take a deep breath and apply gentle pressure over the area

Question 20

20. A patient with a new colostomy should have the hole in the faceplate cut to allow inch around the stoma.
    a. 1 1/4
    b. 1
    c. 1/2
    d. 1/4

Answer 20

d. 1/4

Question 21

21. A nurse is caring for a patient who had bowel surgery 3 days ago and is now beginning to have a well-functioning ostomy. The ostomy drainage
    bag should be emptied whenever it is:
    a. one fourth full.
    b. one half full.
    c. three fourths full.
    d. full

Answer 21

b. one half full.

Question 22

22. A patient with a colostomy asks about foods that can be eaten that will reduce odor in the ostomy drainage bag. The most informative response by the nurse is to say that ostomy odor can be decreased with the intake of:
    a. buttermilk.
    b. eggs.
    c. cucumbers.
    d. beans

Answer 22

a. buttermilk

Question 23

23. The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, “I am so scared.” The nurse’s most supportive response would be:
    a. “Surgeries like yours are very safe.”
    b. “What about your colostomy scares you?”
    c. “Why are you scared?”
    d. “Sounds like someone has been telling you horror stories.”

Answer 23

b. “What about your colostomy scares you?”

Question 24

24. The nurse reminds the patient that digestion of food is a complex process with much of the food breaking down in intestines. The small intestine functions to:
    a. reabsorb sodium and chlorides.
    b. propel waste material toward the anus.
    c. absorb food substances from the bloodstream.
    d. return water from the waste material to the bloodstream.

Answer 24

c. absorb food substances from the bloodstream.

Question 25

25. The nurse caring for a patient who had a colostomy 2 days ago assesses slight bleeding around the stoma when the area is cleansed, colostomy bag filled with gas, pale stoma, and a reddened area under the adhesive of the appliance. The assessment that should be reported immediately is the assessment pertaining to the:
    a. skin irritation.
    b. bleeding around the stoma.
    c. amount of gas in the bag.
    d. pale

Answer 25

D. Pale

Question 26

26. The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that:
    a. an ileostomy is performed to remove stool from the colon, whereas a colostomy is the removal of lower portions of bowel, diverting intestinal contents.
    b. an ileostomy has effluent that is more formed, whereas a colostomy has effluent that is liquid.
    c. a colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.
    d. an ileostomy requires irrigating, whereas a colostomy requires catheterizing

Answer 26

c. a colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.

Question 27

27. The patient with the new colostomy is concerned about how to
    control diarrhea of the effluent. The nurse suggests that diarrhea
    can be controlled by the intake of:
    a. cheese.
    b. apple juice.
    c. raw vegetables.
    d. beans

Answer 27

a. cheese.

Question 28

1. The nurse instructs the patient who has had an ileostomy to modify the diet to include: (Select all that apply.)
   a. increase the protein intake.
   b. choose foods that are high in calories.
   c. select foods that have a milk base.
   d. eat raw vegetables and fruits.
   e. include whole grain products in diet daily.

Answer 28

a. increase the protein intake.
b. choose foods that are high in calories.

Question 29

2. The nurse points out that age-related changes in the intestinal
   tract are relatively insignificant. The changes include: (Select
   all that apply.)
   a. atrophy of the villi in the small intestine.
   b. increased incidence of hemorrhoids.
   c. decreased absorption of fats and vitamin B12.
   d. creation of excessive flatus.
   e. decreased motility in the large intestine

Answer 29

a. atrophy of the villi in the small intestine.
c. decreased absorption of fats and vitamin B12.
d. creation of excessive flatus.

Question 30

3. The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include: (Select all that apply.)
   a. spicy foods.
   b. whole kernel corn.
   c. cucumbers.
   d. tomatoes.
   e. shrimp

Answer 30

B,D,E
b. whole kernel corn.
d. tomatoes.
e. shrimp

Question 31

1. The gastrocolic reflex initiates

Answer 31

Peristalsis

Question 32

2. The nurse assesses a pale, light gray stool and recognizes that the cause of this abnormal color is due to an obstruction in the_____duct.

Answer 32

Bile

Question 33

3. The nurse reminds a group of older adults that a colonoscopy is
   recommended every____
   year(s) after the age of 50.

Answer 33

10