1. The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client?
A) Constipation
B) Diarrhea
C) De
Ans: A
Feedback:
Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will
2. During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?
A) An increase in the client's
Ans: A
Feedback:
When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened,
3. While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants?
A) Golden yellow and loose
B) Dark brown and firm
C) Yellow-brown and pasty
D) Green and
Ans: A
Feedback:
Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and usually have little odor. With formula or cow's milk feedings, infants' stools vary from yellow to brown and are pasty in consistency.
4. Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?
A) Hard, formed
B) Black, tarry
C) Soft, watery
D) Dry, odorous
Ans: C
Feedback:
About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When absorption does not occur properly, such as when the waste products pass through the large intestine rapidly, the stool is soft and watery.
5. A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby?
A) Yellow, loose, odorless
B) Brown, paste-like, some odor
C) Brown, formed, strong odor
D) Black, semiformed, no odor
Ans: A
Feedback:
Breast-fed babies have more frequent stools, and the stools are yellow to golden and loose, usually with little odor. Breast-fed babies can normally have 2 to 10 stools per day.
6. A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior?
A) "When he does this, scold him and he will quit."
B) "I don't understand why this child is losing control
Ans: C
Feedback:
Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet trained often regress and experience soiling when hospitalized, and scolding or acting disgusted only reinforces the behavior.
7. A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?
A) It is painful to sit on a bedpan.
B) The position does not facilitate downward pressure.
C) The position encourages the Valsalva ma
Ans: B
Feedback:
Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining
8. The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change?
A) Decrease high-fiber foods
B) Decrease amount of fluids
C) Omit fruits if eating vege
Ans: D
Feedback:
A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel elimination. Intake of the foods described makes the feces more bulky, so they move through the intestine more quickly. The stool is softer and the
9. A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis?
A) Routine urinalysis
B) Chest x-ray
C) Stool sample
D
Ans: C
Feedback:
Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be confirmed by a stool sample.
10. A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment?
A) It is the most painful assessment method
B) It is the most embarrassing assessment method
C
Ans: D
Feedback:
The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.
11. What are two essential techniques when collecting a stool specimen?
A) Hand hygiene and wearing gloves
B) Following policies and selecting containers
C) Wearing goggles and an isolation gown
D) Using a no-touch method and toilet paper
Ans: A
Feedback:
Use of medical aseptic techniques when collecting a stool specimen is imperative. Hand hygiene, before and after wearing rubber gloves, is essential.
12. What is occult blood?
A) Bright red visible blood
B) Dark black visible blood
C) Blood that contains mucus
D) Blood that cannot be seen
Ans: D
Feedback:
Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a Hematest.
13. A nurse is scheduling diagnostic studies for client. Which test would be performed first?
A) Fecal occult blood test
B) Barium study
C) Endoscopic exam
D) Upper gastrointestinal series
Ans: A
Feedback:
Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo multiple studies. They should follow a logical sequence when more than one test is required for accurate diagnosis; that is, fecal occult blood test
14. A client has had frequent watery stools (diarrhea) for an extended period of time. The client also has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate?
A) Imbalanced Nutrition: Less than Body Req
Ans: B
Feedback:
Bowel elimination problems may also affect other areas of human functioning. For example, excessive diarrhea causes loss of body fluid, with resulting decreased skin turgor and concentrated urine. Deficient Fluid Volume is an appropriate
15. An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea?
A) Heart tones
B) Lung sounds
C) Skin turgor
D) Activity level
Ans: C
Feedback:
When infants and children become ill, they lose most fluids from their extracellular compartment, which quickly leads to dehydration. The nurse would assess skin turgor to identify this problem.
16. A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on:
A) Habitual laxative use is the most common cause of chronic constipation.
B) If laxatives are not effective, the client should begi
Ans: A
Feedback:
Occasional use of laxatives is not harmful for most people, but they should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is
17. A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora?
A) Stool-softening laxatives, such as Colace
B) Increasing fluid intake to 3,000 mL/day
C) Drinki
Ans: D
Feedback:
Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To promote the return of normal flora, the nurse can recommend an intake of fermented dairy products, such as buttermilk or yogurt.
18. A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client?
A) Fowler's
B) Sims'
C) Prone
D) Sitting
Ans: B
Feedback:
A reclining position on the left side (Sims' position) is recommended. The head may be slightly elevated, but Fowler's position should be avoided because the solution will remain in the rectum and expulsion will occur rapidly, resulting i
19. Which is an expected outcome for a client undergoing a bowel training program?
A) Have a soft, formed stool at regular intervals without a laxative.
B) Continue to use laxatives, but use one less irritating to the rectum.
C) Use oil-retention enemas o
Ans: A
Feedback:
Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or
20. A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client?
A) "Just give it a few more days and you should be fine."
B) "Well, that shouldn't happen. Let me recommend a
Ans: C
Feedback:
A combination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has been shown to be as effective as medications in controlling constipation. Caution the client to avoid increasing fiber intake without drinking enough flui
21. A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document?
A) "Ileostomy bag half filled with liquid feces."
B) "Ileostomy bag half filled with hard, formed feces."
C) "Colostomy
Ans: A
Feedback:
The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.
22. A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
A) Pallor
B) Purple-blue
C) Irritation and bleeding
D) Dark red and moist
Ans: D
Feedback:
The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple-blue color (possible ischemia), or bleeding.
23. A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next?
A) Notify the physician immediately.
B) Ask another nurse to check her findings.
C)
Ans: C
Feedback:
Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after surgery, usually within two to five days.
24. A nurse is providing discharge instructions for a client with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care?
A) During the first six to eight weeks after surgery, eat foods high in fiber.
B) Drink at leas
Ans: B
Feedback:
During the first six to eight weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells) as well as any other foods that cause diarrhea or excessive f
25. A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction?
A) Inserted a lubricated, gloved finger into the rectum.
B) Obtain a sharp in
Ans: A
Feedback:
The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray i
26. The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason?
A) Detect abdominal masses
B) Determine abdominal firmness
C) Assess softness of abdominal muscles
D) Assess degree of abdomi
Ans: A
Feedback:
The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention.
27. A nurse is providing care to a client who has undergone a colonoscopy. Which of the following would be most appropriate for the nurse to do after the procedure?
A) Avoid giving solid food
B) Administer a laxative to the client
C) Monitor for rectal bl
Ans: C
Feedback:
The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxativ
28. During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify
Ans: B
Feedback:
The most appropriate nursing diagnosis for the client is perceived constipation, because the client has made a self-diagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed
29. A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ...
A) Allergic to sugar
B) Lactose intolerant
C) Experiencing infectious diarrhea
D) Deficient in fiber
Ans: B
Feedback:
Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine.
30. A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?
A) Increased bowel sounds
B) Abdominal tenderness
C) Areas of distention
D) Muscular resistance
Ans: A
Feedback:
The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.
31. A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client?
A) Oil retention enema
B) Carminative enema
C) Anthelmintic enema
D) Nutritive enema
Ans: C
Feedback:
Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve di
32. A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure?
A) Position the client in supine position as dictated by client comfort and condition.
B) Insert
Ans: C
Feedback:
For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, poi
33. A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition?
A) The peristomal skin is excoriated or irritated becaus
Ans: D
Feedback:
During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting
34. A nurse is following a physician's order to irrigate the NG tube of a client. Which of the following is a recommended guideline in this procedure?
A) Assist client to 30- to 45-degree position, unless this is contraindicated.
B) Draw up 60 mL of salin
Ans: A
Feedback:
To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into
35. Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order.
1. Cleanse entire perianal area and pat dry.
2. Apply skin protectant and allow it to dry.
3. Separate buttocks and apply the pouch to the a
Ans: C
Feedback:
A nurse would not be able to determine if the entire intestinal tract is clear.