Question 1

The nurse is assessing a 31-year-old female patient with abdominal pain.Th nurse,who notes that there is ecchymosis around the area of umbilicus,will document this finding as

Accepted Answer

Cullen sign is ecchymosis around the umbilicus.Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant.Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest),known as McBurney's sign,is a sign of acute appendicitis.

Question 2

A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center.Which instructions will the nurse include in discharge teaching?

Accepted Answer

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

Question 3

Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

Accepted Answer

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

Question 4

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis?

Accepted Answer

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.

Question 5

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to

Accepted Answer

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 enemas or a colonoscopy because of the risk for perforation and peritonitis.

Question 6

Four hours after a bowel resection,a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention.The first action by the nurse should be to

Accepted Answer

Repositioning the tube will frequently facilitate drainage.Because this is a common occurrence,it is not appropriate to notify the health care provider unless other interventions do not resolve the problem.Information about the presence or absence of bowel sounds will not be helpful in improving drainage.Removing the tube and replacing it are unnecessarily traumatic to the patient,so that would only be done if the tube was completely occluded.

Question 7

A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools.What action by the nurse will prevent complications associated with ongoing incontinence?

Accepted Answer

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.Although incontinence briefs may be helpful,unless they are changed frequently,they are likely to increase the risk for skin breakdown.Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa.A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

Question 8

A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness.Vital signs include temperature 102° F (38.3° C),pulse 120,respirations 32,and blood pressure (BP)82/54.Which prescribed intervention should the nurse implement first?

Accepted Answer

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

Question 9

A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia.Which patient teaching will the nurse provide before discharge?

Accepted Answer

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.

Question 10

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease?

Accepted Answer

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

Question 11

A 71-year-old patient had an abdominal-perineal resection for colon cancer.Which nursing action is most important to include in the plan of care for the day after surgery?

Accepted Answer

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.

Question 12

A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy.The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage.The nurse should

Accepted Answer

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.

Question 13

A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea.The nurse anticipates that the patient will need to

Accepted Answer

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.

Question 14

The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient

Accepted Answer

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.

Question 15

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum.Which prescribed intervention will the nurse implement first?

Accepted Answer

Because 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.

Question 16

A 34-year-old female patient with a new ileostomy asks how much drainage to expect.The nurse explains that after the bowel adjusts to the ileostomy,the usual drainage will be about _____ cups.

Accepted Answer

After the proximal small bowel adapts to reabsorb more fluid,the average amount of ileostomy drainage is about 500 mL daily.One cup is about 240 mL.

Question 17

A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours.Which action should the nurse take first?

Accepted Answer

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.

Question 18

A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen.During the initial assessment of the patient,the nurse should

Accepted Answer

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.

Question 19

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome?

Accepted Answer

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 are also associated with IBS,but are not diagnostic criteria.

Question 20

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for

Accepted Answer

Crohn's disease frequently affects the ileum,where absorption of cobalamin occurs.Cobalamin 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.

Quiz 39: Nursing Management: Lower Gastrointestinal Problems