Deck 40: Bowel Elimination

Question 1

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority?

A) Provide oral care after each episode of emesis.
B) Apply a skin barrier to the patient's perineal area.
C) Check the patient to see if he has a fecal impaction.
D) Administer antiemetic medication with a sip of water.

Answer 1

Check the patient to see if he has a fecal impaction.

Question 2

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement?

A) Glass of warmed prune juice
B) Loperamide (Imodium)
C) Oral fiber supplement
D) An oil retention enema

Answer 2

An oil retention enema

Question 3

The nurse is caring for a patient who has diarrhea. What is the priority nursing diagnosis for this patient?

A) Readiness for enhanced knowledge related to prescribed diet modifications
B) Imbalanced nutrition: less than body requirements related to poor appetite
C) Deficient fluid volume related to excessive loss of fluid through stool
D) Anxiety related to incontinence with loose stools and need for clothing change

Answer 3

Deficient fluid volume related to excessive loss of fluid through stool

Question 4

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient's plan of care for the day before the test?

A) Provide the patient with zinc oxide skin barrier cream for the perineal area.
B) Obtain an order for a gentle laxative to be given once the test is completed.
C) Carefully assess the patient's ability to swallow liquids through a straw.
D) Check the patient for allergies to shellfish and iodine-based contrast dyes.

Question 5

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse?

A) Assist the patient to ambulate in the hall.
B) Insert a rectal tube to remove retained flatus.
C) Administer an enema to stimulate peristalsis.
D) Encourage oral intake of fluids and high-fiber foods.

Question 6

The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis of toileting self-care deficit?

A) The patient will demonstrate safe transfer technique between wheelchair and toilet.
B) The call light will be answered promptly when the patient needs to use the toilet.
C) Toileting will be scheduled for the early morning when the patient needs to defecate.
D) Toilet paper and hand-washing items will be kept within easy reach of the patient.

Question 7

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?

A) The patient is recovering from a traumatic brain injury.
B) The patient has not had a bowel movement for 3 days.
C) The patient is to have a lower GI series the following morning.
D) The patient had an upper GI series performed the previous day.

Question 8

The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?

A) The patient has skin breakdown from loose stools
B) The patient is constipated with last BM 3 days ago
C) The patient is on a low-fiber, gluten-free diet
D) The patient has painful bleeding hemorrhoids

Question 9

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?

A) The patient has bowel sounds x 4 quadrants and is passing gas.
B) The patient has no nausea, and abdominal pain is minimal.
C) The patient feels hungry for chicken soup and hot tea.
D) The patient's nasogastric tube was discontinued the previous day.

Question 10

The nurse is caring for a patient who takes laxatives and enemas regularly to ensure that he has a large daily bowel movement. The patient states that he feels constipated if he does not defecate every day. Which nursing diagnosis is most appropriate for this patient?

A) Health-seeking behaviors related to self-prescribed daily bowel regimen
B) Perceived constipation related to professed need for daily laxatives
C) Effective therapeutic regimen management related to defecation routine
D) Disturbed thought processes related to obsession with daily bowel movements

Question 11

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed?

A) Applesauce
B) Orange Popsicle
C) White toast
D) Coffee with cream

Question 12

The nurse is caring for a patient who periodically has small streaks of fresh red blood in his stool. The patient denies abdominal pain or loss of appetite. What is the most likely cause of this patient's bleeding?

A) Hemorrhoids
B) Bleeding gastric ulcer
C) Colon polyps
D) Perforated colon

Question 13

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient's new symptoms?

A) C. difficile infection
B) Paralytic ileus
C) Fecal impaction
D) Salmonella food poisoning

Question 14

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient?

A) Obtain an order to administer a soap suds cleansing enema.
B) Teach the patient how to use the Valsalva maneuver.
C) Discontinue medications that can cause constipation.
D) Assess the patient's usual pattern of bowel movements.

Question 15

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function?

A) Raisin bran with skim milk, fresh fruit, and wheat toast
B) Pancakes with maple syrup, bacon, and coffee with cream
C) Omelet with cheddar cheese, green pepper, and onions
D) Bagel with cream cheese, and strawberry non-fat yogurt

Question 16

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing?

A) Keep the patient on a clear liquid diet for 72 hours.
B) Send the samples to the laboratory while they are still warm.
C) Inform the patient that several stool samples will be needed.
D) Use a sterile container when collecting the stool samples.

Question 17

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse?

A) Keep the patient NPO and document the findings in the chart.
B) Administer a laxative suppository to stimulate peristalsis.
C) Insert a Salem sump nasogastric tube to low continuous suction.
D) Notify the surgeon and prepare the patient to return to surgery.

Question 18

The nurse is caring for a patient with a history of dementia who is incontinent of stool because she cannot communicate the need to defecate. What is the priority action of the nurse?

A) Administer a daily laxative and take the patient to the toilet afterward.
B) Digitally remove stool from the patient's rectum every other day.
C) Insert a rectal tube to facilitate drainage of soft or liquid stool.
D) Begin a prompted toileting program to facilitate bowel continence.

Question 19

The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has the highest priority for the patient?

A) Impaired skin integrity r/t localized skin irritation from liquid stool
B) Social isolation r/t potential leakage of stool from ostomy appliance
C) Knowledge deficit r/t care and maintenance of ostomy appliance
D) Disturbed body image r/t presence of stoma and altered elimination

Question 20

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam?

A) "The back of your throat will be sprayed with numbing medicine."
B) "You will need to have a clear liquid diet and take a laxative tonight."
C) "You will be given a milky liquid to drink shortly before the test starts."
D) "You should not take your dose of warfarin (Coumadin) tonight."

Question 21

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?

A) The patient will remain continent with no perineal skin breakdown.
B) The patient will state satisfaction with use of gait belt for toilet transfers.
C) The patient will regain ability to pull up clothing after using the toilet.
D) Privacy will be provided once the patient is properly positioned on the toilet.

Question 22

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient's dinner tray since they are not allowed prior to the test? (Select all that apply.)

A) Cherry-flavored gelatin
B) Cream of chicken soup
C) Glass of apple juice
D) Coffee with cream and sugar
E) Lemon-flavored Italian ice
F) Can of ginger ale

Question 23

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor?

A) Water-soluble lubricant is applied to the end of the enema tubing.
B) The enema tubing is primed with solution that has been warmed.
C) The patient is positioned comfortably in the right side-lying Sims position.
D) The patient's bedpan is put at the bedside in preparation for use.

Question 24

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions may the nurse delegate to the nursing assistant? (Select all that apply.)

A) Gently cleaning the stoma with warm water and a washcloth.
B) Assessing the stoma and incision for signs of infection or ischemia.
C) Obtaining needed supplies from the clean utility room.
D) Teaching the patient how to care for the ostomy after discharge.
E) Determining which type of ostomy appliance to use.
F) Application of skin protectant to the area surrounding the stoma.