Chapter 30: Promoting Bowel Elimination My Nursing Test Banks

Chapter 30: Promoting Bowel Elimination

Test Bank

MULTIPLE CHOICE

1. The nurse has assessed that a patients 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.

ANS: D

Occult or old blood is suspected when stool changes from a normal brown appearance to a dark black color with a sticky appearance.

DIF: Cognitive Level: Analysis REF: p. 569 OBJ: Theory #2

TOP: Stool Characteristics KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: B

Steatorrhea is defined as stools with abnormally high fat content that are usually frothy, foul smelling, and float on water.

DIF: Cognitive Level: Comprehension REF: p. 569 OBJ: Theory #2

TOP: Terminology KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: C

A patient who is undergoing barium radiograph studies is more prone to constipation than are the other patients.

DIF: Cognitive Level: Application REF: p. 570 OBJ: Theory #3

TOP: Abnormal Characteristics of Stool KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

4. An elderly 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.

ANS: C

A large amount of fluid should be taken to prevent constipation and fecal impaction when using a product with psyllium.

DIF: Cognitive Level: Comprehension REF: p. 570 OBJ: Clinical Practice #1

TOP: Abnormal Characteristics of Stool KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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).

ANS: B

Loperamide (Imodium) is an antidiarrheal; the rest are used to prevent or treat constipation.

DIF: Cognitive Level: Comprehension REF: p. 571, Box 30-2

OBJ: Theory #1 TOP: Medication for Diarrhea

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

6. An elderly 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

ANS: C

The patient may be developing electrolyte imbalance because of the diarrhea, so the best fluid source to offer is Gatorade, which has sodium and potassium. This should be offered 1 to 2 ounces at a time.

DIF: Cognitive Level: Application REF: p. 571, Elder Care

OBJ: Clinical Practice #1 TOP: Abnormal Characteristics of Stool

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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 (e.g., Jell-O).

d.

poultry.

ANS: A

Diarrhea results from the loss of normal intestinal bacteria that are also killed during treatment with antibiotics used to treat a different infection; eating yogurt or drinking buttermilk can help restore normal intestinal flora.

DIF: Cognitive Level: Comprehension REF: p. 574, Patient Teaching

OBJ: Clinical Practice #1 TOP: Abnormal Characteristics of Stool

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

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.

ANS: A

Lactose intolerance is the name for the condition in which diarrhea occurs after consuming milk products.

DIF: Cognitive Level: Knowledge REF: p. 572 OBJ: Theory #2

TOP: Abnormal Characteristics of Stool KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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 abdomen _____ bowel sounds in all four quadrants.

a.

nondistended, firm, with hypoactive

b.

nondistended, soft, with active

c.

distended, firm, with hypoactive

d.

distended, soft, with hyperactive

ANS: B

Normal abdominal assessment data are an abdomen that is soft and nondistended and that has active bowel sounds in all four quadrants.

DIF: Cognitive Level: Comprehension REF: p. 572, Clinical Cues

OBJ: Clinical Practice #3 TOP: Assessment: Bowels

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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

ANS: B

If bowel evacuation has not occurred within 3 days, measures should be taken to assist the patient.

DIF: Cognitive Level: Comprehension REF: p. 573 OBJ: Theory #2

TOP: Abnormal Characteristics of Stool KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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

ANS: D

To get rid of the barium, the patients fluid intake should be increased to 3.5 L, or 3500 mL, and the patient should be given a laxative.

DIF: Cognitive Level: Application REF: p. 573 OBJ: Clinical Practice #1

TOP: Promoting Regular Bowel Elimination

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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 _____ hours without calling back for an appointment.

a.

24

b.

48

c.

72

d.

96

ANS: B

Antidiarrheal medication should not be continued for more than 48 hours without calling a physician.

DIF: Cognitive Level: Comprehension REF: p. 574 OBJ: Clinical Practice #1

TOP: Promoting Regular Bowel Elimination

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

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

b.

300 to 500

c.

200 to 300

d.

50 to 150

ANS: A

The volume of the cleansing enema depends on the age of the patientfor adults, it is between 500 and 1000 mL.

DIF: Cognitive Level: Application REF: p. 577, Skill 31-1

OBJ: Clinical Practice #5 TOP: Enemas

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

14. 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

ANS: C

The oil-retention enema should be retained for 20 minutes.

DIF: Cognitive Level: Comprehension REF: p. 578 OBJ: Clinical Practice #5

TOP: Retention Enemas KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

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.

ANS: D

Solution that is too cool cannot be retained, and solution that is too hot may cause injury to rectal tissues; it is best to warm it to 105 F.

DIF: Cognitive Level: Application REF: p. 585, Steps 30-3

OBJ: Clinical Practice #5 TOP: Cleansing Enemas

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: C

No more than three large-volume enemas are given because of possible electrolyte depletion.

DIF: Cognitive Level: Comprehension REF: p. 576, Safety Alert

OBJ: Clinical Practice #5 TOP: Enemas

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

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 patients:

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.

ANS: B

Stimulation of the sphincter may cause a vagal response as evidenced by bradycardia.

DIF: Cognitive Level: Application REF: p. 579, Steps 30-1

OBJ: Clinical Practice #1 TOP: Fecal Impaction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: reduction of risk

18. A nurse is reinforcing teaching 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 2500 mL daily.

c.

use of a suppository.

d.

use of an enema.

ANS: D

Enemas and stronger laxatives are not considered a part of the program.

DIF: Cognitive Level: Comprehension REF: p. 579, Box 30-3

OBJ: Theory #2 TOP: Bowel Training

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: A

For some patients the taking of a deep breath relaxes muscles and allows passage of the catheter.

DIF: Cognitive Level: Application REF: p. 581, Steps 30-2

OBJ: Clinical Practice #7 TOP: Ileostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. A patient with a new colostomy should have the hole in the faceplate cut to allow _____ inch around the stoma.

a.

1

b.

1

c.

d.

ANS: D

The faceplate should allow inch around the colostomy stoma.

DIF: Cognitive Level: Knowledge REF: p. 584, Skill 30-2

OBJ: Clinical Practice #8 TOP: Colostomy Faceplate

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: B

The ostomy bag should be changed when it is one-third to one-half full so that the weight of the bag will not detach it.

DIF: Cognitive Level: Knowledge REF: p. 584, Skill 30-2

OBJ: Clinical Practice #8 TOP: Ostomy Bag

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

ANS: A

Buttermilk is among the suggested foods that decrease ostomy bag odor.

DIF: Cognitive Level: Comprehension REF: p. 582 OBJ: Clinical Practice #8

TOP: Ostomy Bag KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

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 nurses 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.

ANS: B

The nurse needs to address the patients anxiety and fear first by use of open-ended questioning, because the patient might be focused on a variety of things, including poor body image or the prospect of death. Asking a Why question is not therapeutic and makes the patient defensive.

DIF: Cognitive Level: Application REF: p. 580 OBJ: Theory #5

TOP: Preoperative Colostomy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: coping and adaptation

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.

ANS: C

The small intestine processes the chyme into a more liquid state and absorbs food substances into the bloodstream. All other listed functions are those of the large intestine.

DIF: Cognitive Level: Knowledge REF: p. 568 OBJ: Theory #5

TOP: Intestinal Digestion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

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 stoma.

ANS: D

The pale stoma indicates a compromised blood supply and should be reported immediately to the physician.

DIF: Cognitive Level: Analysis REF: p. 582, Clinical Cues

OBJ: Clinical Practice #8 TOP: Colostomy Stoma

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and early detection of disease

26. The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that a(n):

a.

ileostomy is performed to remove stool from the colon, whereas a colostomy is the removal of lower portions of bowel, diverting intestinal contents.

b.

ileostomy has effluent that is more formed, whereas a colostomy has effluent that is liquid.

c.

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

d.

ileostomy requires irrigating, whereas a colostomy requires catheterizing.

ANS: C

The colostomy is an opening into the colon, with formed effluent requiring irrigation, whereas the ileostomy is an opening in the ileum, with liquid effluent requiring catheterizing.

DIF: Cognitive Level: Comprehension REF: p. 582 OBJ: Theory #7

TOP: Intestinal Diversions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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.

beams.

ANS: A

Cheese can control or decrease the incidence of diarrhea in a colostomy.

DIF: Cognitive Level: Comprehension REF: p. 582 OBJ: Clinical Practice #1

TOP: Control of Diarrhea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

COMPLETION

28. The gastrocolic reflex initiates ________.

ANS:

peristalsis.

Peristalsis is initiated by the gastrocolic reflex, which creates the urge to defecate.

DIF: Cognitive Level: Knowledge REF: p. 568 OBJ: Theory #1

TOP: Bowel Elimination KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

29. 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.

ANS:

bile

An obstruction in the bile ducts prevents bile salts from entering the bile. Bile salts give the feces its characteristic brown color.

DIF: Cognitive Level: Comprehension REF: p. 569 OBJ: Theory #2

TOP: Bowel Elimination KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

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

ANS:

10

ten

Healthy People 2020 recommends a colonoscopy every 10 years in persons over the age of 50.

DIF: Cognitive Level: Knowledge REF: p. 569 OBJ: Clinical Practice #1

TOP: Colonoscopies KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

MULTIPLE RESPONSE

31. 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.

ANS: A, B

Patients with ileostomies have lost their lower bowel and need food sources that are high in calories and vitamins. Water intake should be up to 10 cups a day to make up for the water reabsorption usually done in the colon. High residue foods such as whole grain products and raw vegetables and fruits can irritate the intestine.

DIF: Cognitive Level: Comprehension REF: p. 582, Patient Teaching

OBJ: Theory #7 TOP: Food Appropriate for Ileostomies

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

32. 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.

ANS: A, C, D

With age there is a decrease in the villi in the small intestine that decreases the absorption of fats and vitamin B12. Motility frequently decreases in the large intestine.

DIF: Cognitive Level: Comprehension REF: p. 568 OBJ: Theory #1

TOP: Age-Related Changes in the Intestinal Tract

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

33. 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.

ANS: B, D, E

Whole-kernel corn, tomatoes, and shrimp are among the food that can cause an obstruction in a colostomy.

DIF: Cognitive Level: Comprehension REF: p. 582 OBJ: Clinical Practice #4

TOP: Obstructive Foods KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

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