Chapter 43: Nursing Management: Lower Gastrointestinal Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 43: Nursing Management: Lower Gastrointestinal Problems

Test Bank

MULTIPLE CHOICE

1. A patient who is hospitalized with watery, incontinent diarrhea is diagnosed with Clostridium difficile. Which action will the nurse include in the plan of care?

a.

Order a diet with no dairy products for the patient.

b.

Place the patient in a private room with contact isolation.

c.

Teach the patient about why antibiotics are not being used.

d.

Educate the patient about proper food handling and storage.

ANS: B

Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

DIF: Cognitive Level: Application REF: 1009-1010 TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

2. A 67-year-old patient tells the nurse, I have problems with constipation now that I am older, so I use a suppository every morning. Which action should the nurse take first?

a.

Encourage the patient to increase oral fluid intake.

b.

Inform the patient that a daily bowel movement is unnecessary.

c.

Assess the patient about individual risk factors for constipation.

d.

Suggest that the patient increase dietary intake of high-fiber foods.

ANS: C

The nurses initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

DIF: Cognitive Level: Application REF: 1012-1013

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. In teaching a patient who has chronic constipation about the use of psyllium (Metamucil), which information will the nurse include?

a.

Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives.

b.

Dietary sources of fiber should be eliminated to prevent excessive gas formation.

c.

Use of this type of laxative to prevent constipation does not cause adverse effects.

d.

Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D

A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

DIF: Cognitive Level: Application REF: 1012-1014

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. The nurse is obtaining a history for a 23-year-old woman who is being evaluated for acute lower abdominal pain and vomiting. Which question will be most useful in determining the cause of the patients symptoms?

a.

Is it possible that you are pregnant?

b.

Can you tell me more about the pain?

c.

What type of foods do you usually eat?

d.

What is your usual elimination pattern?

ANS: B

A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patients symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.

DIF: Cognitive Level: Application REF: 1015-1016

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. Two days after an exploratory laparotomy with a resection of a short segment of small bowel, a patient complains of gas pains and abdominal distention. Which nursing action is best to take at this time?

a.

Give a return-flow enema.

b.

Assist the patient to ambulate.

c.

Administer the ordered IV morphine sulfate.

d.

Insert the ordered promethazine (Phenergan) suppository.

ANS: B

Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patients symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

DIF: Cognitive Level: Application REF: 1016-1017

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. A patient who has blunt abdominal trauma after an automobile accident is complaining of severe pain. A peritoneal lavage returns brown drainage with fecal material. Which action will the nurse plan to take next?

a.

Auscultate the bowel sounds.

b.

Prepare the patient for surgery.

c.

Check the patients oral temperature.

d.

Obtain information about the accident.

ANS: B

Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

DIF: Cognitive Level: Application REF: 1018-1019 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. A patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?

a.

Check for rebound tenderness.

b.

Assist the patient to cough and deep breathe.

c.

Apply an ice pack to the right lower quadrant.

d.

Encourage the patient to take sips of clear liquids.

ANS: C

The patients clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

DIF: Cognitive Level: Application REF: 1020-1021

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. Which nursing action will be included in the plan of care for a patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)?

a.

Encourage the patient to express feelings and ask questions about IBS.

b.

Suggest that the patient increase the intake of milk and other dairy products.

c.

Educate the patient about the use of alosetron (Lotronex) to reduce symptoms.

d.

Teach the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).

ANS: A

Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

DIF: Cognitive Level: Application REF: 1017-1018

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to

a.

place the patient on NPO status.

b.

administer IV metoclopramide (Reglan).

c.

teach the patient about total colectomy surgery.

d.

administer cobalamin (vitamin B12) injections.

ANS: A

An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.

DIF: Cognitive Level: Application REF: 1022-1025 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. Which nursing action will the nurse include in the plan of care when admitting a patient with an exacerbation of inflammatory bowel disease (IBD)?

a.

Restrict oral fluid intake.

b.

Monitor stools for blood.

c.

Increase dietary fiber intake.

d.

Ambulate four times daily.

ANS: B

Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

DIF: Cognitive Level: Application REF: 1024-1025 | 1028-1029

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. After the nurse has finished teaching a patient with ulcerative colitis about sulfasalazine (Azulfidine), which patient statement indicates that the teaching has been effective?

a.

I will need to use a sunscreen when I am outdoors.

b.

I will need to avoid contact with people who are sick.

c.

The medication will need to be tapered if I need surgery.

d.

The medication will prevent infections that cause the diarrhea.

ANS: A

Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

DIF: Cognitive Level: Application REF: 1026-1027 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

12. A patient who has an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?

a.

The patient uses incontinence briefs to contain loose stools.

b.

The patient asks for antidiarrheal medication after each stool.

c.

The patient uses witch hazel compresses to decrease anal irritation.

d.

The patient cleans the perianal area with soap and water after each stool.

ANS: C

Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

DIF: Cognitive Level: Application REF: 1029 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

13. After the nurse has provided patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD), which diet choice by the patient indicates a need for more teaching?

a.

Scrambled eggs

b.

White toast and jam

c.

Oatmeal with cream

d.

Pancakes with syrup

ANS: C

During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

DIF: Cognitive Level: Application REF: 1030-1031 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

14. A patient who has had a total proctocolectomy and permanent ileostomy tells the nurse, I cannot bear to even look at the stoma. I do not think I can manage all these changes. Which is the best action by the nurse?

a.

Develop a detailed written plan for ostomy care for the patient.

b.

Ask the patient more about the concerns with stoma management.

c.

Reassure the patient that care for the ileostomy will become easier.

d.

Postpone any patient teaching until the patient adjusts to the ileostomy.

ANS: B

Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patients feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patients ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

DIF: Cognitive Level: Application REF: 1042 | 1044-1046

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. When caring for a patient who has a new diagnosis of Crohns disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months, the nurse will plan to teach the patient about

a.

medication use.

b.

fluid restriction.

c.

enteral nutrition.

d.

activity restrictions.

ANS: A

Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

DIF: Cognitive Level: Application REF: 1025-1027 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

16. A patient with Crohns disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. The nurse will teach the patient

a.

to clean the perianal area carefully after any stools.

b.

about fistula formation between the bowel and bladder.

c.

to empty the bladder before and after sexual intercourse.

d.

about the effects of corticosteroid use on immune function.

ANS: B

Fistulas between the bowel and bladder occur in Crohns disease and can lead to UTI. There is no information indicating that the patients risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patients urine indicate that a fistula has occurred.

DIF: Cognitive Level: Application REF: 1023-1024

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for

a.

referred back pain.

b.

metabolic alkalosis.

c.

projectile vomiting.

d.

abdominal distention.

ANS: D

Abdominal distention is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction.

DIF: Cognitive Level: Application REF: 1031-1033

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. When preparing for an annual physical exam for a patient who is 50 years old, the nurse will plan to teach the patient about

a.

endoscopy.

b.

colonoscopy.

c.

computerized tomography screening.

d.

carcinoembryonic antigen (CEA) testing.

ANS: B

At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

DIF: Cognitive Level: Application REF: 1035-1037 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

19. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will

a.

give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria.

b.

teach the patient that activities such as sitting at the bedside will be started the first postoperative day.

c.

instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir.

d.

administer polyethylene glycol lavage solution (GoLYTELY) to ensure that the bowel is empty before the surgery.

ANS: D

A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery.

DIF: Cognitive Level: Application REF: 1036-1038

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to

a.

confirm the diagnosis of colon cancer.

b.

monitor the tumor status after surgery.

c.

identify the extent of cancer spread or metastasis.

d.

determine the need for postoperative chemotherapy.

ANS: B

CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

DIF: Cognitive Level: Comprehension REF: 1036-1037

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. Which nursing action is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?

a.

Teach about a low-residue diet.

b.

Monitor output from the stoma.

c.

Assess the perineal drainage and incision.

d.

Encourage acceptance of the colostomy stoma.

ANS: C

Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

DIF: Cognitive Level: Application REF: 1039 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

22. During the initial postoperative assessment of a patients stoma formed from a transverse colostomy, the nurse finds it to be deep pink with moderate edema and a small amount of bleeding. The nurse should

a.

document the stoma assessment.

b.

monitor the stoma every 30 minutes.

c.

notify the surgeon about the stoma appearance.

d.

place an ice pack on the stoma to reduce swelling.

ANS: A

The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

DIF: Cognitive Level: Application REF: 1041-1042

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A patient who has ulcerative colitis has a proctocolectomy and ileostomy. Which information will the nurse include in patient teaching?

a.

Restrict fluid intake to prevent constant liquid drainage from the stoma.

b.

Use care when eating high-fiber foods to avoid obstruction of the ileum.

c.

Irrigate the ileostomy daily to avoid having to wear a drainage appliance.

d.

Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B

High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

DIF: Cognitive Level: Application REF: 1042 | 1044-1045

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient

a.

hangs the irrigating container about 18 inches above the stoma.

b.

stops the irrigation and removes the irrigating cone if cramping occurs.

c.

inserts the irrigation tubing no further than 4 to 6 inches into the stoma.

d.

fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: A

The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

DIF: Cognitive Level: Application REF: 1045 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

25. The nurse explains to a patient with a new ileostomy that after the bowel adjusts to the ileostomy, the usual drainage will be about

a.

1 cup.

b.

2 cups.

c.

3 cups.

d.

1 quart.

ANS: B

After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily.

DIF: Cognitive Level: Comprehension REF: 1042 | 1044-1045

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will plan to

a.

give stool softeners.

b.

administer IV fluids.

c.

order a diet high in fiber and fluids.

d.

prepare the patient for colonoscopy.

ANS: B

A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have a colonoscopy because of the risk for perforation and peritonitis.

DIF: Cognitive Level: Application REF: 1047 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

27. Which patient education will the nurse provide before discharge for a patient who has had a herniorrhaphy to repair an incarcerated inguinal hernia?

a.

Encourage the patient to cough.

b.

Provide sitz baths several times daily.

c.

Avoid use of acetaminophen (Tylenol) for pain.

d.

Apply a scrotal support and ice to reduce swelling.

ANS: D

A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

DIF: Cognitive Level: Application REF: 1049-1050

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

28. After the nurse has completed teaching a patient with newly diagnosed celiac disease, which breakfast choice by the patient indicates good understanding of the information?

a.

Corn tortilla with eggs

b.

Bagel with cream cheese

c.

Oatmeal with non-fat milk

d.

Whole wheat toast with butter

ANS: A

Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.

DIF: Cognitive Level: Application REF: 1050 | 1051-1052

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

29. Which instructions will the nurse include in discharge teaching for a patient who has had a hemorrhoidectomy at an outpatient surgical center?

a.

Maintain a low-residue diet until the surgical area is healed.

b.

Use ice packs on the perianal area to relieve pain and swelling.

c.

Take prescribed pain medications before a bowel movement is expected.

d.

Delay having a bowel movement for several days until healing has occurred.

ANS: C

Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean.

DIF: Cognitive Level: Application REF: 1053

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

30. A patient calls the clinic and tells the nurse about a new onset of severe and frequent, diarrhea. The nurse anticipates that the patient will need to

a.

collect a stool specimen.

b.

prepare for colonoscopy.

c.

schedule a barium enema.

d.

have blood cultures drawn.

ANS: A

Acute diarrhea is usually caused by an infectious process and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

DIF: Cognitive Level: Application REF: 1007-1008 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

31. A patient with Crohns disease has megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for

a.

oral ferrous sulfate tablets.

b.

regular blood transfusions.

c.

iron dextran (Imferon) infusion.

d.

cobalamin (B12) nasal spray or injections.

ANS: D

Crohns disease frequently affects the ileum, where absorption of cobalamin occurs, and it must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

DIF: Cognitive Level: Application REF: 1024-1025 | 1028

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

32. When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as

a.

rebound pain.

b.

Cullen sign.

c.

Rovsing sign.

d.

McBurney point.

ANS: C

Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. McBurney point, rebound pain, and Cullen sign are used to describe other aspects of the abdominal assessment.

DIF: Cognitive Level: Knowledge REF: 1020

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

33. A critically ill patient develops incontinence of watery stools. What action will be best for the nurse to take to prevent complications associated with ongoing incontinence?

a.

Insert a rectal tube.

b.

Use incontinence briefs.

c.

Implement fecal management system.

d.

Assist the patient to a bedside commode or to the bathroom at frequent intervals.

ANS: C

Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. Incontinence briefs may be helpful but, unless they are changed frequently, are likely to increase the risk for skin breakdown. A critically ill patient will not be able to use the commode or bathroom.

DIF: Cognitive Level: Application REF: 1012

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

34. When interviewing a patient with abdominal pain and possible irritable bowel syndrome, which question will be most important for the nurse to ask?

a.

Have you been passing a lot of gas?

b.

What foods affect your bowel patterns?

c.

Do you have any abdominal distention?

d.

How long have you had abdominal pain?

ANS: D

One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance also are associated with IBS, but are not diagnostic criteria.

DIF: Cognitive Level: Application REF: 1017-1018

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

35. Which of these prescribed interventions will the nurse implement first when caring for a patient who has just been diagnosed with peritonitis caused by a ruptured diverticulum?

a.

Administer morphine sulfate 4 mg IV.

b.

Infuse metronidazole (Flagyl) 500 mg IV.

c.

Send the patient for a computerized tomography scan.

d.

Insert a nasogastric (NG) tube and connect it to intermittent low suction.

ANS: B

Since peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

DIF: Cognitive Level: Application REF: 1021-1022

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

36. Which action should the nurse take first when a patient calls the clinic complaining of diarrhea of 24 hours duration?

a.

Ask the patient to describe the character of the stools and any associated symptoms.

b.

Inform the patient that laboratory testing of blood and stool specimens will be necessary.

c.

Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.

d.

Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: A

The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

DIF: Cognitive Level: Application REF: 1008-1009

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

37. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness. The vital signs include temperature 101 F (38.3 C), pulse 130, respirations 34, and blood pressure (BP) 84/50. Which of the following interventions should the nurse implement first?

a.

Administer IV ketorolac (Toradol) 15 mg.

b.

Draw blood for a complete blood count (CBC).

c.

Obtain a computed tomography (CT) scan of the abdomen.

d.

Infuse 1000 mL of lactated Ringers solution over 30 minutes.

ANS: D

The priority for this patient is to treat the patients hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

DIF: Cognitive Level: Application REF: 1016

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

38. Following an exploratory laparotomy and bowel resection, a patient who has a nasogastric tube to suction complains of nausea and stomach distention. The first action by the nurse should be to

a.

auscultate for hypotonic bowel sounds.

b.

notify the patients health care provider.

c.

reposition the tube and check for placement.

d.

remove the tube and replace it with a new one.

ANS: C

Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence or absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient.

DIF: Cognitive Level: Application REF: 1016-1017

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

39. A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, the nurse should

a.

assess the BP and pulse.

b.

remove the knife to assess the wound.

c.

determine the presence of Rovsing sign.

d.

insert a urinary catheter and assess for hematuria.

ANS: A

The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

DIF: Cognitive Level: Application REF: 1019-1020

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

40. Which of these nursing activities included in the care of a patient with a new colostomy should the nurse delegate to nursing assistive personnel (NAP)?

a.

Document the appearance of the stoma.

b.

Place the pouching system over the ostomy.

c.

Drain and measure the output from the ostomy.

d.

Check the skin around the ostomy for breakdown.

ANS: C

Draining and measuring the output from the ostomy is included in NAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

DIF: Cognitive Level: Application REF: 1044

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

41. The nurse who is interviewing a 40-year-old obtains information about the following patient problems. Which information is most important to communicate to the health care provider?

a.

The patient had an appendectomy at age 17.

b.

The patient smokes a pack/day of cigarettes.

c.

The patient has a history of frequent constipation.

d.

The patient has recently noticed blood in the stools.

ANS: D

Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further testing by the health care provider. The other patient information also will be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

DIF: Cognitive Level: Application REF: 1035-1036

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

42. The RN and nursing assistive personnel (NAP) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to NAP?

a.

Auscultation for bowel sounds

b.

Applying petroleum jelly to the lips

c.

Irrigation of the nasogastric (NG) tube with saline

d.

Assessment of the nose for irritation

ANS: B

NAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

DIF: Cognitive Level: Application REF: 1033-1034

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

43. A hospitalized patient who has been taking antibiotics for several days develops watery diarrhea. Which action should the nurse take first?

a.

Notify the health care provider.

b.

Obtain a stool specimen for analysis.

c.

Provide education about handwashing.

d.

Place the patient on contact precautions.

ANS: D

The patients history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions also are appropriate but can be accomplished after contact precautions are implemented.

DIF: Cognitive Level: Application REF: 1008-1010

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

44. After receiving change-of-shift report, which of the following patients should the nurse assess first?

a.

A patient whose new ileostomy has drained 800 mL over the previous 8 hours

b.

A patient with familial adenomatous polyposis who has occult blood in the stool

c.

A patient with ulcerative colitis who has had six liquid stools in the previous 4 hours

d.

A patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D

The patients abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients also should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

DIF: Cognitive Level: Analysis REF: 1031-1034

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

45. A patient with Crohns disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about all of these symptoms. Which symptom is most important to communicate to the health care provider?

a.

Nausea

b.

Joint pain

c.

Frequent headaches

d.

Elevated temperature

ANS: D

Since infliximab suppresses immune function, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but do not indicate any potentially life-threatening complications.

DIF: Cognitive Level: Application REF: 1026-1027

OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

46. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. Which information will be included in patient teaching?

a.

This type of colostomy is usually temporary.

b.

Soft, formed stool can be expected as drainage.

c.

Stool will be expelled from both ostomy stomas.

d.

Irrigations can regulate drainage from the stomas.

ANS: A

A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

DIF: Cognitive Level: Application REF: 1040-1041 | 1042 | 1044-1045

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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