Question 1

The nurse instilled 60 mL of irrigant into an indwelling fecal drainage device. The client's output was 140 mL. What would the nurse chart as the client's output of stool?

Accepted Answer

The client's output of stool would be the total output (140 mL) minus the volume of irrigant instilled (60 mL), which equals 80 mL.

Question 2

Which action should the nurse tell the parent to take to assess a 2-year-old child for pinworms?

Accepted Answer

The "tape test" is a common method to diagnose pinworms. It involves pressing clear tape against the child's rectum in the morning before they bathe or use the toilet, as pinworm eggs are laid around the anus at night. This method can capture eggs on the tape, which can then be viewed under a microscope for diagnosis.

Question 3

A male patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally every 12 hours. The patient reports that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?

Accepted Answer

Cephalexin, like other antibiotics, can disrupt the normal flora of the gut, leading to diarrhea. Consuming yogurt, which contains probiotics, can help restore the gut's normal flora and potentially reduce the risk of antibiotic-associated diarrhea. Stopping the drug immediately or taking an antidiarrheal agent without consulting a healthcare provider might not be appropriate, and increasing fiber intake might not directly address the underlying issue of disrupted gut flora.

Question 4

A patient with severe hemorrhoids is incontinent of liquid stool. Which intervention is contraindicated?

Accepted Answer

Applying an indwelling fecal drainage device is contraindicated in patients with severe hemorrhoids because it can exacerbate the condition and cause additional pain or damage.

Question 5

In which area is the appendix located?

Accepted Answer

The appendix is located off of the cecum, which is the beginning of the large intestine, at the junction of the small and large intestines.

Question 6

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test?

Accepted Answer

Vitamin C (ascorbic acid) can cause a false-negative fecal occult blood test because it has antioxidant properties that can interfere with the chemical reaction used in the test to detect blood.

Question 7

The nurse is obtaining a bowel elimination history from an 80-year-old patient. The patient states, "Sometimes when I go to the bathroom, I push real hard, hold my breath, and plug my nose." Which action should the nurse take first?

Accepted Answer

The nurse should first check the patient's medical history for heart disease or glaucoma because straining and holding one's breath (Valsalva maneuver) can increase intrathoracic pressure, potentially leading to adverse effects in patients with these conditions.

Question 8

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to:

Accepted Answer

Irrigating the stoma on a schedule can help control bowel movements, allowing some patients with a descending or sigmoid colostomy to manage their bowel evacuation without the constant use of an ostomy pouch.

Question 9

A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient's care plan?

Accepted Answer

Morphine and other opioids commonly cause constipation due to their effects on the gastrointestinal tract, leading to decreased gut motility. Therefore, patients starting on morphine should be assessed for the risk of developing constipation.

Question 10

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication?

Accepted Answer

Paralytic ileus is a common postoperative complication characterized by the absence of bowel sounds due to temporary paralysis of the bowel. This can occur after abdominal surgery as the intestines may be slow to resume normal function.

Question 11

When changing a diaper, the nurse observes that a 2-day-old infant has passed green-black, tarry stools. What should the nurse do?

Accepted Answer

The green-black, tarry stools observed in a 2-day-old infant are known as meconium, which is the first stool passed by newborns. This is a normal finding and indicates that the infant's digestive system is functioning properly.

Question 12

The nurse is caring for a patient who has a continent ileostomy. Which intervention will the nurse add to the plan of care?

Accepted Answer

A continent ileostomy involves creating an internal pouch with a valve, allowing the patient to drain it by inserting a catheter or tube into the stoma.

Question 13

The registered nurse is working on a medical-surgical floor. Which behavior by a licensed practical nurse (LPN) would cause the nurse to intervene immediately?

Accepted Answer

The answer of The registered nurse is working on a...

Question 14

The nurse is performing an abdominal assessment on a client with irritable bowel syndrome. The nurse has just finished inspection of the abdomen. Which action should the nurse take next?

Accepted Answer

The correct sequence for abdominal assessment is inspection, auscultation, percussion, and then palpation. Auscultation should follow inspection to avoid altering bowel sounds that might occur if the abdomen is palpated or percussed first.

Question 15

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing?

Accepted Answer

Yogurt contains probiotics, which can help restore the balance of good bacteria in the gut and promote healing from an intestinal infection.

Question 16

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?

Accepted Answer

Collecting a stool specimen that contains 20 to 30 mL of liquid stool is the correct action to help confirm the diagnosis of an intestinal infection. Laboratory analysis of the stool can identify pathogens such as bacteria, viruses, or parasites that may be causing the infection.

Question 17

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching?

Accepted Answer

A stoma that is pale, dusky, or black in color indicates impaired blood supply to the stoma, which is a medical emergency requiring immediate attention.

Question 18

Considering normal developmental and physical maturation in children, for which age would a goal of "Achieves bowel control by the end of this month" be most realistic?

Accepted Answer

Most children achieve bowel control between 2 and 3 years of age, making a goal of achieving bowel control by the end of the month most realistic for a child who is 3 years old.

Question 19

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Accepted Answer

Stopping the irrigation temporarily is the appropriate action when a client complains of abdominal cramps during a colostomy irrigation. This can help alleviate the cramps and prevent further discomfort or potential injury.

Question 20

The nurse is seeing a patient at home with a new colostomy. In formulating the plan of care, what is the priority goal for this patient? The patient will:

Accepted Answer

The answer of The nurse is seeing a patient at...

Quiz 29: Bowel Elimination