Chapter 49 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 49

Question 1

Type: MCSA

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurses best response?

1. The sitting position decreases the contractions of the muscles of the pelvic floor.

2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool.

3. The sitting position increases the pressure within the abdomen.

4. The sitting position inhibits the urge to urinate, allowing one to defecate.

Correct Answer: 2

Rationale 1: Expulsion of the feces is assisted by contraction of the abdominal muscles and the diaphragm, which increases abdominal pressure, and by contraction of the muscles of the pelvic floor, which moves the feces through the anal canal.

Rationale 2: Normal defecation is facilitated by thigh flexion, which increases the pressure within the abdomen, and a sitting position, which increases the downward pressure on the rectum.

Rationale 3: Thigh flexion increases the pressure within the abdomen.

Rationale 4: The sitting position increases the downward pressure on the rectum.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe the physiology of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1212

Question 2

Type: MCSA

A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond?

1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor.

2. The clients emotions are causing the gas formation.

3. The sensory nerves in the rectum are being stimulated.

4. The client has swallowed too much air while eating.

Correct Answer: 1

Rationale 1: The actions of the microorganisms are responsible for the odor produced and also the color of the feces.

Rationale 2: Extreme stimulation of the clients emotions would result in large amounts of mucus being secreted.

Rationale 3: The sensory nerves, when stimulated, give one the desire to defecate, not form gas.

Rationale 4: Eating too fast or talking while eating does cause the formation of gas but does not contribute to the odor.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe the physiology of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1212

Question 3

Type: MCSA

The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation?

1. An adult who is on bed rest

2. An infant who is breast-fed

3. A school-age child at recess

4. A toddler who is now walking

Correct Answer: 1

Rationale 1: Adults who are on bed rest are at greatest risk for developing constipation.

Rationale 2: Infants who are breast-fed pass stools frequently, usually after each feeding, because the intestine is immature and water is not well absorbed.

Rationale 3: School-age children may delay defecation because of play, but their activity still promotes regular bowel movements.

Rationale 4: A toddler who is now walking has some control of defecation, and the nervous and muscular systems are sufficiently well developed to permit bowel control.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1215

Question 4

Type: MCSA

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which response should the nurse make to explain why this practice should be changed?

1. If you continue to ignore the urge to defecate, the urge is ultimately lost.

2. It is best to suppress the urge rather than suffer embarrassment at work.

3. This is a common practice, and it will strengthen the reflex later.

4. You will get the urge later; dont worry.

Correct Answer: 1

Rationale 1: When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost.

Rationale 2: This response does not explain why the client should change the practice.

Rationale 3: Ignoring the urge will not strengthen the reflex later. Eventually the urge will be lost.

Rationale 4: The urge can be lost.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1215

Question 5

Type: MCSA

The nurse is preparing to assess a clients fecal elimination status. Which activity will the nurse complete during this assessment?

1. Obtain a nursing history.

2. Interpret results of diagnostic tests.

3. Perform a physical examination.

4. Set goals with the client.

Correct Answer: 1

Rationale 1: Assessment of fecal elimination includes a nursing history and also a review of any data from the clients records.

Rationale 2: Interpretation of diagnostic test results would demonstrate evaluation of the nursing process.

Rationale 3: Performing a physical examination would demonstrate implementation of the nursing process.

Rationale 4: Setting goals for the client demonstrates the planning step of the nursing process.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe methods used to assess fecal elimination.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1220

Question 6

Type: MCSA

The nurse determines that an adult clients feces are normal. What did the nurse assess to come to this conclusion?

1. Black in color

2. Cylindrical in shape

3. Pungent in odor

4. Yellow in color

Correct Answer: 2

Rationale 1: Black is abnormal.

Rationale 2: Cylindrical in contour is a normal characteristic of feces because it takes the shape of the rectum.

Rationale 3: Pungent is abnormal, but aromatic odor is normal.

Rationale 4: Yellow is the color of an infants feces, not an adults.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1213

Question 7

Type: MCSA

The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do?

1. Change the daily routine.

2. Decrease fluid consumption.

3. Increase fiber in the diet.

4. Note the precipitating event.

Correct Answer: 4

Rationale 1: Changing ones daily routine can cause or contribute to diarrhea.

Rationale 2: Decreasing fluid consumption may cause constipation. If a client has diarrhea and still decreases fluid intake, this can contribute to dehydration.

Rationale 3: Increasing fiber in the diet when one already has diarrhea would just make matters worse.

Rationale 4: Psychological stress such as anxiety, medications, food allergies, and certain diseases can cause diarrhea. Noting the event can help identify and stop the cause.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1221

Question 8

Type: MCSA

The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective?

1. The client continues to ask for his pain medication.

2. The client decreases his fluid consumption.

3. The client refuses to eat the bran flakes on his tray.

4. The client walks around the unit several times a day.

Correct Answer: 4

Rationale 1: Pain medication contributes to constipation, especially those that are opiates.

Rationale 2: Decreasing fluid intake further contributes to constipation.

Rationale 3: Refusing to eat bran flakes would also promote constipation.

Rationale 4: Increased activity such as walking promotes gastric motility, which increases bowel function.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1223

Question 9

Type: MCSA

A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with

1. bowel incontinence.

2. constipation.

3. diarrhea.

4. fecal impaction.

Correct Answer: 2

Rationale 1: Bowel incontinence is the loss of voluntary ability to control feces.

Rationale 2: Hard, dry, formed stool is characteristic of constipation.

Rationale 3: Diarrhea is the passage of liquid feces.

Rationale 4: Fecal impaction is a mass of hardened feces in the folds of the rectum.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1215

Question 10

Type: MCSA

What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest?

1. Bowel Incontinence

2. Constipation

3. Diarrhea

4. Disturbed Body Image

Correct Answer: 2

Rationale 1: Lack of sphincter control contributes to bowel incontinence, not bed rest.

Rationale 2: Lack of activity, as in bed rest, is a major contributor to constipation. Lack of movement slows bowel movements.

Rationale 3: Diarrhea would come from a GI upset triggered by diseases, medication, or diet.

Rationale 4: Disturbed body image would affect a client who has undergone a bowel diversion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1221

Question 11

Type: MCSA

The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client?

1. Client will defecate regularly.

2. Client will increase the amount of sugar in the diet.

3. Client will limit fluid intake.

4. Client will regain normal stool consistency.

Correct Answer: 4

Rationale 1: Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal. The problem needs to be corrected first.

Rationale 2: Increasing the amount of sugar in the diet will just add to the diarrhea.

Rationale 3: Because the client is experiencing diarrhea, which can dehydrate the client and promote electrolyte loss, limiting fluid would not be appropriate.

Rationale 4: Because this client is experiencing diarrhea, the goal would be to regain normal stool consistency, which would be less water in the stool and a more formed consistency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1221

Question 12

Type: MCSA

The nurse is instructing a client on ostomy care. What should be included in this teaching?

1. Change the drainage pouch daily.

2. Clothing of a special style will be needed now that a pouch is worn.

3. Stick a pin into the drainage pouch to relieve any gas buildup.

4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

Correct Answer: 4

Rationale 1: The drainage pouches are expensive, and they can be used for up to a week before being changed. Just daily rinsing and cleaning is necessary.

Rationale 2: No special clothing has to be worn with a colostomy pouch. The client can wear the same clothes he or she wore prior to the surgery.

Rationale 3: If a pin is stuck into the pouch, a hole will be left and it will cause leakage, which is not recommended.

Rationale 4: The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other skin.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1235

Question 13

Type: MCSA

Which assessment technique will the nurse use first when examining a client with a fecal elimination problem?

1. Auscultation

2. Inspection

3. Palpation

4. Percussion

Correct Answer: 2

Rationale 1: After inspection, the nurse should then auscultate for bowel sounds.

Rationale 2: The nurse will first inspect the clients abdominal region.

Rationale 3: This technique would be used last in the assessment of a client with a fecal elimination problem.

Rationale 4: This technique would be used after inspection and auscultation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe methods used to assess fecal elimination.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1220

Question 14

Type: MCSA

The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision?

1. Bowel sounds active in all four quadrants

2. Clay-colored stool

3. Increased appetite

4. Semisolid and moist stool

Correct Answer: 2

Rationale 1: Bowel sounds active in all four quadrants is indicative of normal bowel activity.

Rationale 2: Clay-colored stools would be an indication of a problem in the GI tract. Clay color is a sign of the absence of bile pigment (bile obstruction).

Rationale 3: If the GI tract were compromised, the client would have a decrease in appetite, not an increase.

Rationale 4: A semisolid and moist stool indicates normal bowel function.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1213

Question 15

Type: MCSA

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

1. Drink two to four glasses of water daily.

2. Include more spicy foods and sugar in the diet.

3. Include more whole grains in the diet.

4. Use enemas as desired.

Correct Answer: 3

Rationale 1: For regular elimination, six to eight glasses of water should be consumed daily.

Rationale 2: Increasing the consumption of spicy foods and sugar will cause diarrhea, which is not a normal fecal pattern.

Rationale 3: Eating more whole grains will increase fiber in the diet, which increases bulk and volume.

Rationale 4: The constant use of enemas and laxatives will promote dependence.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1222

Question 16

Type: MCSA

The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate?

1. Apply pressure over the stoma.

2. Clean the stoma and pat dry.

3. Dilate the stoma.

4. Scrub the stoma.

Correct Answer: 2

Rationale 1: Applying pressure over the stoma may damage the stoma.

Rationale 2: Stoma care includes cleaning the area and patting dry.

Rationale 3: A physicians order is needed if the stoma is to be dilated. Dilating is not routine.

Rationale 4: Scrubbing would cause the stoma to bleed because the area is very vascular.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy.

MNL Learning Outcome: 4.9.3. Correlate alterations in bowel elimination to client care.

Page Number: 1234

Question 17

Type: MCSA

A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema?

1. Hold the solution for a short time.

2. Lie in the left lateral position.

3. Lie in the right lateral position.

4. Take fast breaths through the nose.

Correct Answer: 2

Rationale 1: Once the enema is given, the client should hold the solution as long as possible for the best results.

Rationale 2: The client lies in the left lateral position in order to clean the rectum and sigmoid.

Rationale 3: The client lies in the left lateral position, not the right, in order to clean the rectum and sigmoid.

Rationale 4: The client should take slow deep breaths through the mouth. This will enable the client to hold the solution being given.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1228

Question 18

Type: MCSA

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action?

1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon

2. Exerts a lower osmotic pressure than the surrounding interstitial fluid

3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon

4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon

Correct Answer: 1

Rationale 1: A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon.

Rationale 2: A hypotonic solution exerts a lower osmotic pressure than the surrounding interstitial fluid.

Rationale 3: An isotonic solution is the safest enema solution to use. It exerts the same osmotic pressure as the interstitial fluid surrounding the colon.

Rationale 4: Soapsuds stimulate peristalsis by increasing the volume in the colon and irritating the colon.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1226

Question 19

Type: MCSA

After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon?

1. Flatus

2. Mass peristalsis

3. Haustral churning

4. Peristalsis

Correct Answer: 2

Rationale 1: Flatus is largely air and the by-products of the digestion of carbohydrates.

Rationale 2: Mass peristalsis involves a wave of powerful muscular contraction that moves over large areas of the colon. Mass peristalsis most commonly occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day.

Rationale 3: Haustral churning involves movement of the chyme back and forth within the haustra. This action aids in the absorption of water and moves the contents forward to the next haustra.

Rationale 4: Peristalsis is wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls; it propels the intestinal contents forward.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1211

Question 20

Type: MCSA

The nurse determines that a clients fecal elimination is pale in color. This finding supports which client behavior obtained during the health history?

1. The client rarely eats animal protein, and ingests milk and cheese at several meals each day.

2. The client rarely eats fruits or vegetables.

3. The client uses laxatives routinely.

4. The client drinks 8 to 10 8-ounce glasses of water each day.

Correct Answer: 1

Rationale 1: Stool that is pale in color is seen in those who ingest a diet high in milk and milk products and low in meat.

Rationale 2: Eating a diet low in fruits and vegetables will not produce pale stool.

Rationale 3: Using laxatives routinely will not produce pale stool.

Rationale 4: Drinking 8 to 10 8-ounce glasses of water each day will not produce pale stool.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Distinguish normal from abnormal characteristics and constituents of feces.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1213

Question 21

Type: MCMA

An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client?

Standard Text: Select all that apply.

1. Normal patterns of elimination are different for everyone.

2. Increase fiber intake to 2035 grams a day.

3. Engage in enjoyable exercise.

4. Ignore the urge to have a bowel movement.

5. Drink six to eight glasses of fluid daily.

Correct Answer: 1, 2, 3, 5

Rationale 1: Older adults should be advised that normal patterns of bowel elimination vary considerably. For some, a normal pattern might be every other day; for others, twice a day.

Rationale 2: Constipation can be relieved by increasing the fiber intake to 2035 grams per day.

Rationale 3: Adequate exercise is a preventative measure for constipation.

Rationale 4: Responding to the gastrocolic reflex, and not ignoring it, also helps with constipation.

Rationale 5: Daily fluid intake of six to eight glasses is an essential preventive measure for constipation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1213

Question 22

Type: MCSA

A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client?

1. Assist the client to move in bed.

2. Restrict fluids.

3. Obtain an order for a rectal tube.

4. Provide a diet rich in foods that create flatulence.

Correct Answer: 3

Rationale 1: Activity does help with the expulsion of flatus; however, the client is recovering from abdominal surgery, and will not be able to participate in sufficient movement and exercise to pass the accumulated gas.

Rationale 2: Restricting fluids will not help with the expulsion of flatus.

Rationale 3: If excessive gas cannot be expelled through the anus, it might be necessary to insert a rectal tube to remove it.

Rationale 4: Providing a diet rich in foods that create flatulence will cause the problem to be worse.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1217

Question 23

Type: MCSA

A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing

1. constipation.

2. diarrhea.

3. trapped flatus.

4. fecal impaction.

Correct Answer: 4

Rationale 1: Liquid stool is not an indication of constipation.

Rationale 2: The liquid stool associated with abdominal distention, anorexia, nausea, and vomiting is not an indication of diarrhea.

Rationale 3: Trapped flatus does not cause the seeping of liquid stool.

Rationale 4: A client who has a fecal impaction will experience the passage of liquid fecal seepage and no normal stool. The liquid portion of the feces seeps out around the impacted mass. Symptoms include anorexia, abdominal distention, nausea, and vomiting.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify common causes and effects of selected fecal elimination problems.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1215

Question 24

Type: MCMA

A client has occasional bouts of constipation, and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do?

Standard Text: Select all that apply.

1. Establish a regular exercise regimen.

2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet.

3. Maintain fluid intake of 2000 to 3000 mL a day.

4. Do not ignore the urge to defecate.

5. Use over-the-counter medications to treat constipation.

Correct Answer: 1, 2, 3, 4

Rationale 1: Measures to promote healthy defecation include establishing a regular exercise regimen.

Rationale 2: Measures to promote healthy defecation include the intake of high-fiber foods such as vegetables, fruits, and whole grains.

Rationale 3: Measures to promote healthy defecation include maintaining a fluid intake of 2000 to 3000 mL per day.

Rationale 4: Measures to promote healthy defecation include not ignoring the urge to defecate.

Rationale 5: Measures to promote healthy defecation include avoiding the use of over-the-counter medications to treat constipation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1221

Question 25

Type: MCSA

A hospitalized client tells the nurse of the inability to have a bowel movement because too many people are around. What should the nurse do to promote normal fecal elimination for this client?

1. Provide a laxative.

2. Assist the client to the bathroom to ensure privacy.

3. Restrict fluids.

4. Assist the client with ambulation.

Correct Answer: 2

Rationale 1: Providing a laxative does not address the issue that there are too many people around for the client to feel comfortable with bowel evacuation.

Rationale 2: Privacy during defecation is extremely important to many people. The nurse should therefore provide as much privacy as possible for such clients, but might need to stay with those who are too weak to be left alone.

Rationale 3: Restricting fluids would encourage constipation.

Rationale 4: Assisting the client with ambulation does not address the issue of too many people being around for the client to feel comfortable with defecation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify measures that maintain normal fecal elimination patterns.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1221

Question 26

Type: MCSA

A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within

1. 1 to 3 hours.

2. 10 to 20 minutes.

3. 5 to 10 minutes.

4. 10 to 15 minutes.

Correct Answer: 1

Rationale 1: Oil retention enemas take effect within 1 to 3 hours.

Rationale 2: Enemas using a hypertonic solution take effect in 5 to 10 minutes.

Rationale 3: Soapsuds enemas take effect in 10 to 15 minutes.

Rationale 4: Enemas using hypotonic or isotonic solutions take effect in 10 to 20 minutes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1227

Question 27

Type: MCMA

A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client?

Standard Text: Select all that apply.

1. Hypertonic

2. Hypotonic

3. Soapsuds

4. Oil retention

5. Isotonic

Correct Answer: 2, 5

Rationale 1: Hypertonic enema solutions draw water into the colon.

Rationale 2: Hypotonic enema solutions soften the feces.

Rationale 3: Soapsuds enema solutions irritate the mucosa.

Rationale 4: Oil retention enema solutions lubricate the feces.

Rationale 5: Isotonic enema solutions soften the feces.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Describe the purpose and action of commonly used enema solutions.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1226

Question 28

Type: MCMA

The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should

Standard Text: Select all that apply.

1. be changed daily.

2. protect the skin.

3. collect stool.

4. control odor.

5. be open, so the client can empty it sporadically throughout the day.

Correct Answer: 2, 3, 4

Rationale 1: An ostomy appliance does not need to be changed daily.

Rationale 2: An ostomy appliance should protect the skin.

Rationale 3: An ostomy appliance should collect stool.

Rationale 4: An ostomy appliance should control odor.

Rationale 5: An ostomy appliance can be either open or closed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe essentials of fecal stoma care for clients with an ostomy.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1232

Question 29

Type: MCSA

The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP safely perform to meet a clients fecal elimination needs?

1. Provide a fracture pan to a client on bed rest.

2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing enema.

3. Change a clients ostomy device.

4. Irrigate a clients ostomy.

Correct Answer: 1

Rationale 1: Providing a client who is on bed rest with a fracture pan is within the skill level of UAP.

Rationale 2: The client has a prolapsed rectum. The nurse should be providing the enema.

Rationale 3: The client has an ostomy. The nurse should be providing ostomy care.

Rationale 4: Irrigation of an ostomy should be done by the nurse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Recognize when it is appropriate to delegate assistance with fecal elimination to unlicensed assistive personnel.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1224

Question 30

Type: MCSA

During morning care, a UAP notes that thick green drainage is seeping around the appliance of a clients new ostomy. What should the UAP have been instructed to do?

1. Clean around the drainage.

2. Remove the ostomy appliance and cover the stoma with toilet tissue.

3. Perform complete ostomy care.

4. Report the drainage to the nurse.

Correct Answer: 4

Rationale 1: UAP should have been instructed to clean drainage off of the skin.

Rationale 2: UAP should not be instructed to remove the appliance and cover the stoma with toilet tissue.

Rationale 3: UAP should not be instructed to perform care to a new ostomy.

Rationale 4: Care of a new ostomy is not delegated to UAP. However, aspects of ostomy function are observed during usual care, and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. Recognize when it is appropriate to delegate assistance with fecal elimination to unlicensed assistive personnel.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1233

Question 31

Type: SEQ

The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Clean and dry the peristomal skin and stoma.

Choice 2. Prepare and apply the skin barrier.

Choice 3. Empty the pouch and remove the ostomy barrier.

Choice 4. Assess the stoma and peristomal skin.

Choice 5. Apply the pouch.

Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed.

Correct Answer: 3, 1, 4, 6, 2, 5

Rationale 1: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Rationale 2: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Rationale 3: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Rationale 4: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Rationale 5: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Rationale 6: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Changing a bowel diversion ostomy appliance.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1234

Question 32

Type: MCSA

While administering an enema, the client complains of abdominal cramping. What should the nurse do?

1. Raise the height of the solution container.

2. Clamp the flow for 30 seconds, and restart at a slower rate.

3. Discontinue the enema infusion.

4. Assist the client to a supine position.

Correct Answer: 2

Rationale 1: Raising the height of the enema solution container will cause the solution to infuse faster, leading to more abdominal cramping.

Rationale 2: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution.

Rationale 3: The enema should not be discontinued.

Rationale 4: The supine position will not reduce the clients abdominal cramping.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: a. Administering an enema.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1229

Question 33

Type: MCMA

A client has received a return-flow enema. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Number of times the solution was changed.

2. Type of solution.

3. Length of time the solution was retained.

4. The amount, color, and consistency of the return.

5. Client relief of flatus and abdominal distention.

Correct Answer: 2, 3, 4, 5

Rationale 1: The nurse does not need to document the number of times the solution was changed.

Rationale 2: For a return-flow enema, the nurse should document the type of solution used.

Rationale 3: For a return-flow enema, the nurse should document the length of time the solution was retained.

Rationale 4: For a return-flow enema, the nurse should document the amount, color, and consistency of the return.

Rationale 5: For a return-flow enema, the nurse should document the clients relief of flatus and abdominal distention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1229

Question 34

Type: MCMA

The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided?

Standard Text: Select all that apply.

1. Any change in stoma size

2. Condition of the skin around the stoma

3. Amount and type of drainage

4. Clients response to the procedure

5. Degree of bowel sounds after care provided

Correct Answer: 1, 2, 3, 4

Rationale 1: After ostomy care, the nurse should document any changes in stoma size.

Rationale 2: After ostomy care, the nurse should document the condition of the skin around the stoma.

Rationale 3: After ostomy care, the nurse should document the amount and type of drainage.

Rationale 4: After ostomy care, the nurse should document the clients response to the procedure.

Rationale 5: The nurse should assess the clients bowel sounds before ostomy care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Demonstrate appropriate documentation and reporting related to fecal elimination.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1235

Question 35

Type: MCMA

During an assessment, the nurse notes that a clients stool is black. Which medication should the nurse consider as causing this clients change in stool color?

Standard Text: Select all that apply.

1. Iron

2. Aspirin

3. Antacids

4. Antibiotics

5. Pepto-Bismol

Correct Answer: 1, 2, 5

Rationale 1: Iron salts lead to black stool because of the oxidation of the iron.

Rationale 2: Any drug that causes gastrointestinal bleeding, such as aspirin, can cause the stool to be black.

Rationale 3: Antacids can cause a whitish discoloration or white specks in the stool.

Rationale 4: Antibiotics may cause a gray-green discoloration of the stool.

Rationale 5: Pepto-Bismol causes stools to be black.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify factors that influence fecal elimination and patterns of defecation.

MNL Learning Outcome: 4.9.2. Recognize factors that affect bowel elimination.

Page Number: 1213

Question 36

Type: MCMA
The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client?

Standard Text: Select all that apply.

1. Assess perianal skin.

2. Irrigate the pouch every shift.

3. Maintain the drainage system.

4. Change the bag every 72 hours.

5. Explain the purpose of the system to the client.

Correct Answer: 1, 3, 4, 5

Rationale 1: For the client with a fecal incontinence pouch, the nurse should regularly assess the perianal skin area.

Rationale 2: Fecal incontinence pouches are not irrigated.

Rationale 3: For the client with a fecal incontinence pouch, the nurse should maintain the drainage system.

Rationale 4: For the client with a fecal incontinence pouch, the nurse should change the bag every 72 hours or sooner if there is leakage.

Rationale 5: For the client with a fecal incontinence pouch, the nurse should explain the purpose of the pouch to the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the life span

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems.

MNL Learning Outcome: 4.9.4. Implement the nursing process in the care of the client with altered gastrointestinal function.

Page Number: 1231

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