Skills cpt 34 & 43 Bowel questions Flashcards
An immobilized patient has a history of constipation and takes a stool softener at home. Which breakfast selection would be best?
A) Scrambled eggs, bagel with jelly, orange juice
B) Mixed fruit, oatmeal, whole wheat toast
C) Banana, donut, rice cereal with milk
D) Pancakes with syrup, bacon strips, apple juice
B
Foods that promote peristalsis are needed; these include high-fiber foods such as raw fruit, whole grains, and green leafy vegetables.
A patient has a nasogastric tube after abdominal surgery. Which action by the nurse best maintains the patency of the air vent?
A) Irrigating the blue pigtail with 10 mL of air
B) Keeping the blue pigtail above the patients stomach
C) Irrigating the blue pigtail with 10 to 20 mL of normal saline
D) Measuring the patients nasogastric output twice each shift
A
Irrigating the air vent with air, whether with 10 mL using a catheter-tipped syringe or with a pop of air from an Asepto syringe, will maintain the patency of the air vent, also known as the blue pigtail.
The nurse is preparing to verify the placement of a patients nasogastric tube. Which method of placement verification by the nurse would best indicate that the end of the tube is in the stomach?
A) Checking the pH of the aspirated gastric contents
B) Auscultating the stomach while air is injected into the nasogastric tube
C) Listening for the return of the patients bowel sounds
D) Obtaining gastric fluid in the tube when aspirating with a syringe
A
The best method, of those listed, is to check the pH of the aspirated gastric contents to ensure that gastric contents are in the tube. Gastric aspirates usually have a pH of 4 or less.
An older patient with limited mobility and strength is recovering from hip surgery and needs to use the bedpan. Which action by the nurse would best facilitate this procedure?
A) Lightly sprinkling a small amount of powder on the bedpan
B) Rolling the patient slightly on his side for better positioning
C) Encouraging the patient to pull up on the overhead trapeze
D) Obtaining the assistance of at least two other staff members
D
Because this patient is unable to safely and predictably help with moving, obtaining extra staff members would provide the safest method. Additional people may still be needed even if the other actions are taken.
An older patient needs to have a fecal impaction removed digitally. The nurse should stop the procedure if which patient information is obtained?
A) Blood pressure changes from 120/76 to 128/88
B) Blood pressure changes from 114/78 to 206/70
C) Heart rate changes from 74 to 58
D) Heart rate changes from 82 to 96
C
Stimulation of the vagus nerve can cause bradycardia. The patient must have vital signs obtained as a baseline before the procedure is begun.
A postoperative patient is suspected of having a wound infection. Which method would be most appropriate for the nurse to use when obtaining an anaerobic culture?
A) Touching the wound edges with the swab from the culture tube
B) Aspirating the drainage using a 21-gauge needle attached to a syringe
C) Using the culture swab, then crushing the attached medium ampule
D) Aspirating the drainage using the sterile tip of a 10-mL syringe
D
For an anaerobic culture, the specimen must be placed in a special medium container. No needle is used in the wound area to obtain the specimen; the standard culture swab with the attached medium ampule also is not used
A patient with suspected sepsis is to have blood cultures obtained but is currently receiving antibiotics. What is the most appropriate nursing action?
A) Call the physician for further clarification of the order.
B) Stop the scheduled antibiotics until the specimens are drawn.
C) Notify the laboratory which antibiotics the patient is receiving.
D) Scrub the venipuncture site for 2 minutes for a sterile specimen.
C
Because antibiotics may interrupt growth of the organism in the laboratory, the nurse must notify the laboratory regarding the antibiotics the patient is currently receiving. It is always best to initiate blood cultures before a patient begins antibiotic therapy, but the patient may develop an infection against which the ordered antibiotic is not effective. The antibiotics should not be stopped.
A nurse in the diabetic clinic is assessing blood glucose levels in patients ranging from infants to the elderly. Which techniques would best ensure that the nurse obtains an adequate amount of blood for testing any of these patients? (Select all that apply)
A) Hold the area to be punctured in a dependent position.
B) Squeeze the area to be punctured.
C) Warm the area to be punctured.
D) Gently hit the area to be punctured.
A & C
Having the puncture site in dependent position increases blood flow to the area. Warming the area to be punctured promotes vasodilation, which facilitates bleeding. Squeezing and gently hitting the area are not appropriate actions.
An unconscious elderly patient with poor circulation has to have an arterial blood gas drawn. Which nursing diagnosis would be given priority during and after the procedure?
A) Ineffective airway clearance
B) Impaired gas exchange
C) Risk for injury
D) Deficient knowledge regarding arterial blood gases
C
The site used is of great importance because the patient has poor circulation. Injury could occur if the wrong site was used, or if the technique was inappropriately done. The radial area is often used because a strong pulse is usually palpable. The patient is unconscious, so knowledge deficit would not be an appropriate nursing diagnosis, and the focus of the question is on the procedure, not on the underlying problem for which the procedure is needed.
A patient needs to expectorate a sputum specimen. The nurse’s teaching has been effective if the patient is seen doing which activity as part of the procedure?
A) Brushing his teeth with toothpaste before producing the specimen
B) Rinsing his mouth with mouthwash before producing the specimen
C) Providing the specimen immediately after awakening before eating
D) Taking a few sips of water to loosen respiratory secretions
C
The sputum specimen will be most concentrated and free of food particles if obtained before breakfast. Toothpaste and mouthwashes decrease the viability of microorganisms and therefore should not be used.
