Question 1

While inspecting a patient's stool, a nurse notices a small amount of black, tarry blood with a distinctive old-blood odor that appears to have been partially digested. The nurse identifies this type of blood as

Accepted Answer

Melena is a medical term used to describe black, tarry, and partially digested blood that appears in the stool. It has a distinct old-blood odor and indicates bleeding from the upper gastrointestinal tract. Occult blood refers to hidden blood in the stool that cannot be seen with the naked eye, and frank blood refers to bright red blood that can be seen in the stool. Steatorrhea is the medical term for stool that is high in fat content and appears pale, oily, and foul-smelling.

Question 2

After having an enema tube inserted into the rectum, a patient begins to exhibit symptoms of a vagal response. A nurse should immediately do which of the following?

Accepted Answer

The answer of After having an enema tube inserted into...

Question 3

A primary care physician has ordered a high enema for a patient admitted for constipation. When administering the high enema, a nurse will

Accepted Answer

Option D is the correct choice since it describes the correct procedure for administering a high enema. The enema solution is typically instilled in increments, with the patient lying on their left side for the first half and then repositioned to supine and right lateral side-lying positions for the rest. This allows the solution to reach different areas of the colon and promote more complete evacuation. Options A, B, and C contain incorrect information and are not part of the standard procedure for administering a high enema.

Question 4

After having an enema tube inserted into the rectum, a patient begins to complain of dizziness, shortness of breath, and chest pain. A nurse identifies that these symptoms indicate

Accepted Answer

The symptoms of dizziness, shortness of breath, and chest pain are indicative of a vagal response, which can be triggered by stimulation of the vagus nerve during insertion of the enema tube. This can result in a lowering of heart rate and blood pressure, which can cause these symptoms.

Question 5

A patient is admitted for a bowel diversion caused by colon cancer. A nurse explains to a certified nursing assistant that another name for fecal material collected in an ostomy appliance is ____________________.

Accepted Answer

The answer of A patient is admitted for a bowel...

Question 6

A male patient has told a nurse that he occasionally fights constipation. Teaching the patient how to prevent constipation and promote normal elimination, the nurse instructs him to

Accepted Answer

Drinking at least 2000 mL fluid every day, but limiting the amount of caffeine to 300 mg, is the most appropriate choice to prevent constipation and promote normal elimination. Increasing fiber intake should be done gradually, and taking a stool softener or laxative every day is not a sustainable solution. Eating small amounts at meals is not necessarily effective in preventing constipation.

Question 7

Following a patient's surgery, a nurse will initiate which of the following implementations to stimulate peristalsis?

Accepted Answer

Ambulation, getting the patient up in a chair for meals, and encouraging fiber intake stimulate peristalsis.

Question 8

A patient with Crohn disease underwent a bowel diversion. The distal portion of the colon was not removed, allowing it time to rest and heal. A nurse identifies that this type of bowel diversion is known as an

Accepted Answer

A colostomy involves diverting the colon through an opening in the abdominal wall, allowing the distal portion to rest and heal. An ileostomy involves diverting the small intestine, not the colon. A Kock pouch and continent ostomy are specific types of ileal pouch-anal anastomosis and not relevant to this scenario.

Question 9

A nurse stops administering an enema because the patient develops bradycardia. The nurse understands the patient has had a(n) ____________________ response as a result of stimulating a specific nerve.

Accepted Answer

The answer of A nurse stops administering an enema because...

Question 10

A patient with a new colostomy has many needs. The care that a nurse plans for the patient will include which of the following?

Accepted Answer

Administering pain medication, emptying the appliance bag to prevent skin excoriation, educating the patient on foods that increase flatus, and assessing educational needs are all important aspects of care for a patient with a new colostomy. Avoiding eye contact (C) is not recommended as it can make the patient feel uncomfortable and unaccepted.

Question 11

A patient was seen in the clinic for removal of a fecal impaction. A nurse provides patient teaching to help prevent recurrent constipation and impaction. Which of the following instructions might the nurse include in the teaching?

Accepted Answer

Delaying toileting can lead to stool hardening and impaction, so it is important for the patient to respond promptly to the urge to defecate. Increasing fiber in the diet can add bulk to the stool and promote regular bowel movements. Exercise can also help stimulate bowel activity. Limiting fluid intake prior to eating may actually make constipation worse, so it would not be included in patient teaching. Increasing sugar in the diet may worsen constipation and is therefore not a helpful instruction.

Question 12

An instructor is discussing the various types of solutions used for enemas. A student shows the need for additional instruction by saying:

Accepted Answer

Tap water should never be used for enemas, as it can cause electrolyte imbalances and fluid shifts. Instead, sterile or distilled water should be used. This student is showing the need for correction and additional instruction.

Question 13

A doctor orders a guaiac test on a patient's stool sample. A nurse identifies that this type of test is used to detect the presence of

Accepted Answer

A guaiac test is used to detect the presence of occult blood in stool, which is not visible to the naked eye. Occult blood can indicate gastrointestinal bleeding, which can be a sign of various conditions, including colorectal cancer. Frank blood and melena are two types of visible blood in stool and do not require a guaiac test to detect. Pancreatitis is a condition involving inflammation of the pancreas and would not be detected by a guaiac test.

Question 14

Before the removal of an impaction, a nurse is instructed to give a patient an enema to soften the hard stool. The nurse determines that the correct type of enema in this situation is a(n)

Accepted Answer

An oil retention enema is the most appropriate choice for softening hard stool before removal of an impaction. The oil in the enema helps lubricate the stool, making it easier to pass. Kayexalate is used to treat high levels of potassium in the blood, a return flow enema is typically used for bowel training or to empty the colon, and a Harris flush is not a standard enema type.

Question 15

An older adult patient admitted for diarrhea caused by gastroenteritis states, "My stools are much less frequent and aren't as watery today." The nurse determines that the antibiotic treatment is therapeutically effective. The nurse understands that the symptoms of gastroenteritis are the result of

Accepted Answer

Gastroenteritis is an infection of the gastrointestinal system that typically causes diarrhea, often watery in nature. Antibiotic treatment is effective when the infectious agent is bacterial rather than viral. The symptoms of gastroenteritis are commonly the result of chemical changes in the bowel with resulting rapid transit time. Structural changes in the bowel or normal changes due to the aging process would not typically result in the symptoms of gastroenteritis. Decreases in the patient's activity level may contribute to constipation, but would not typically cause the symptoms of gastroenteritis.

Question 16

A patient with dementia is confused, unable to provide self-care, and drinks only a few sips at a time. It is the responsibility of the nurse to ensure that the patient receives adequate amounts of fluid to prevent dehydration. The nurse should

Accepted Answer

Offering the patient a drink of water or other beverage every 15 minutes is the best choice as the patient is only able to drink a few sips at a time and may not consistently remember to drink. This ensures that the patient receives adequate amounts of fluid to prevent dehydration. Option A is not frequent enough, option B is too infrequent, and option D may not be feasible or necessary in all cases. However, involving family members in the patient's care and encouraging them to assist with offering fluids can be helpful.

Question 17

A patient requires the removal of flatus, but not the removal of stool as with other types of enemas. A nurse identifies that this may be accomplished by using

Accepted Answer

All of the options listed, A) A Harris flush, B) A return flow enema, and C) A siphon enema, are techniques used to remove flatus from the bowel. These methods are designed to relieve gas without necessarily removing stool, which is the primary goal in this patient's care.

Question 18

A nurse explains to a patient that it is wise to avoid taking a laxative every day because of the problems it can cause. The patient demonstrates understanding by saying laxative abuse can result in which of the following?

Accepted Answer

Taking laxatives every day can lead to fluid and electrolyte imbalances, the need for increasing dosages of laxative, loss of natural contractility in the bowel, and increased risk for an impaction. It can also lead to the development of irritable bowel syndrome. It is best to avoid taking laxatives every day and instead, focus on implementing lifestyle changes to promote regular bowel movements.

Question 19

While inspecting a patient's stool, a nurse notices that the stool appears fluffy, is floating on the water, and has a foul odor. The nurse identifies this type of stool as

Accepted Answer

The described stool characteristics indicate steatorrhea, which is caused by excess fat content in the stool due to malabsorption in the intestines. This often leads to fluffy, floating, and foul-smelling stools. Tenesmus refers to a feeling of incomplete bowel movement, effluence refers to the discharge of fluid, and melena refers to black, tarry stools due to upper gastrointestinal bleeding.

Question 20

A nurse can expect that which of the following patients are likely to suffer from fecal incontinence?

Accepted Answer

Patients with dementia, paraplegia, or mental challenges may have impaired control over bowel movements, increasing the likelihood of fecal incontinence.

Quiz 30: Bowel Elimination and Care