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NURS 6002 Exam 1 exam with 100- correct answers.docx
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NURS 6002 Exam 1 examwith 100% correct answers
A nurse is assessing the abdomen of a patient who is experiencing
frequent bouts of diarrhea. The nurse first observes the contour of
the abdomen, noting any masses, scars, or areas of distention.
What action would the nurse perform next?
A. Auscultate the abdomen using an orderly clockwise approach to
all abdominal quadrants
B. Percuss all quadrants of the abdomen in a systematic clockwise
manner to identify masses, fluid, or air in the abdomen.
C. Lightly palpate over the abdominal quadrants; first checking for
any areas of pain or discomfort.
D. Deeply palpate over the abdominal quadrants, noting muscular
resistance, tenderness, organ enlargement, or masses. - answer A
A nurse is administering a large-volume cleansing enema to a
patient prior to surgery. Once the enema solution is introduced, the
patient complains of severe cramping. What would be the
appropriate nursing intervention in this situation.
A. Elevate the head of the bed 30 degrees and reposition the rectal
tube
B. Place the patient in a supine position and modify the amount of
solution
C. Lower the solution container and check the temperature and flow
rate
D. Remove the rectal tube and notify the PCP - answer C
,If the solution is too cold or the flow rate too fast, severe cramping
may result.
A nurse working in a hospital includes abdominal assessment as
part of patient assessment. In which patients would a nurse expect
to find decreased or absent bowel sounds after listening for 5
minutes? Select all that apply.
A. A patient diagnosed with peritonitis
B. A patient who is on prolonged bedrest
C. A patient who has diarrhea
D. A patient who has gastroenteritis
E. A patient who has an early bowel obstruction
F. A patient who has paralytic ileus caused by surgery - answer A, B,
F
Decreased or absent bowel sounds, evidenced by only after
listening for 5 minutes, signify the absence of bowel motility,
commonly associated with peritonitis, paralytic ileus, and/or
prolonged immobility. Hyperactive bowel sounds indicate increased
motility, commonly caused by diarrhea, gastroenteritis, or early
bowel obstruction
A nurse assesses the stool of patients who are experiencing GI
problems. In which patients would diarrhea be a possible finding?
Select all that apply.
A. A patient who is taking narcotics for pain
B. A patient who is taking laxatives
C. A patient who is taking diuretics
D. A patient who is dehydrated
E. A patient who is taking amoxicillin for an infection
,F. A patient taking OTC antacids - answer B, E, F
Diarrhea is a potential effect of treatment with amoxicillin
clavulanate, laxatives, or OTC antacids. Narcotics, diuretics, and
dehydration may lead to constipation.
A patient has a fecal impaction. The nurse correctly administers an
oil-retention enema by:
A. Administering a large volume of solution (500-1000 mL)
B. Mixing milk and molasses in equal parts for an enema
C. Instructing the patient to retain the enema for at least 30
minutes
D. Administering the enema while the patient is sitting on the toilet
- answer C
The usual amount of solution administered with a retention enema
is 150-200 mL for enema for an adult. The milk and molasses
mixture is a carminative enema that helps expel flatus. The patient
should be instructed to lie on the left side of the bed as dictated by
patient condition and comfort.
A nurse prepares to assist a patient with her newly created
ileostomy. Which recommended patient teaching points would the
nurse stress. Select all that apply.
A. "When you inspect the stoma, it should be dark purple-blue."
B. "The size of the stoma will stabilize within 2 weeks."
C. "Keep the skin around the stoma site clean and moist."
D. "The stool from an ileostomy is normally liquid."
E. "You should eat dark green vegetables to control the odor of the
stool."
, F. "You may have a tendency to develop food blockages." - answer
D, E, F
The nurse should encourage the intake of dark green leafy
vegetables because they contain chlorophyll, which helps deodorize
the feces. Patients wth ileostomies need to be aware they may
experience a tendency to develop food blockages, especially when
high-fiber foods are consumed. The stoma should be dark pink to
red and moist. Stoma size should stabilize within 4-6 weeks, and the
skin around the stoma site should be kept clean and dry.
A nurse is preparing a hospitalized patient for a colonoscopy. Which
nursing action is the recommended preparation for this test?
A. Have the patient follow a clear liquid diet 24-48 hours before the
test.
B. Have the patient take Dulcolax and ingest a gallon of bowel
cleaner on day 1.
C. Prepare the patient for the use of general anesthesia during the
test.
D. Explain that barium contrast mixture will be given to drink before
the test. - answer A
Prep for a colonoscopy includes a clear liquid diet 24 to 48 hours
before the test along with a 2-day bowel prep of a strong cathartic
and Dulcolax on day 1 and enema on day 2 or a 1-day bowel prep
that consists of ingestion of a gallon of bowel cleanser in a short
period of time. Conscious sedation, not general anesthesia, will be
given for a colonoscopy. Barium contrast mixture is given to drink
before an upper GI and small-bowel series of tests.
A nurse is performing digital removal of stool on a 74-year-old
female patient with a fecal impaction. During the procedure the
patient tells the nurse that she is feeling dizzy and nauseated, and
then she vomits. What should be the nurse's next action?
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