Exam (elaborations)
Chapter 37_ Bowel Elimination (2)
- Course
- Nursing 2024
- Institution
- Nursing 2024
Chapter 37_ Bowel Elimination (2)
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During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurseshould proceed with the client's abdominal assessment by next performing: - CORRECT
ANSWER-auscultation.
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any
bowel sounds. How would this be documented? - CORRECT ANSWER-"All four abdominal
quadrants auscultated. Inaudible bowel sounds."
When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the
color on the test paper to: - CORRECT ANSWER-Blue
A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage
more comfortable. - CORRECT ANSWER-False
The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which
interventions are appropriate suggestions? Select all that apply. - CORRECT
ANSWER-Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely
before applying the ostomy pouch.
Apply a commercially available skin barrier before applying the ostomy pouch.
While administering a cleansing enema, the client displays lightheadedness, nausea, and has
clammy skin. The nurse would implement which priority action? - CORRECT ANSWER-Stop the
procedure, monitor heart rate and blood pressure
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most
logical sequence of tests to ensure an accurate diagnosis? - CORRECT ANSWER-fecal occult
blood test, barium studies, endoscopic examination
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the
nurse place the client? - CORRECT ANSWER-Sims
A client wishes to increase fiber to promote more regular bowel movements. Which food will the
nurse recommend that the client consume? - CORRECT ANSWER-brown rice
A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding
vitamin C 3 days before testing? - CORRECT ANSWER-Avoid more than 250 mg.
Which client is most likely to require interventions in order to maintain regular bowel patterns? -
CORRECT ANSWER-a client whose neuropathic pain requires multiple doses of opioids each day
A nurse is caring for a client with primary constipation. Which factor is responsible for primary
constipation? - CORRECT ANSWER-inadequate intake of liquid
Which factor is related to developmental changes in bowel habits for older adult clients? -
CORRECT ANSWER-Weakened pelvic muscles lead to constipation.
A nurse needs to administer a hypertonic enema solution to the client. Which actions must the
nurse perform? Select all that apply. - CORRECT ANSWER-Help the client into a Sims' position.
Compress the container as the solution instills.
Encourage the client to retain the solution.
, The nurse has presented an educational in-service about caring for clients who have newly
created ostomies. The nurse asks participants, "How will you know when a client begins to accept
the altered body image?" Which responses by participants indicates a correct understanding of the
material? Select all that apply. - CORRECT ANSWER-"The client is willing to look at the stoma."
"The client makes neutral or positive statements about the ostomy."
"The client expresses interest in learning self-care."
When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest
to the nurse a causative factor? - CORRECT ANSWER-The client returned from a foreign country
2 days ago.
The nurse is conducting teaching with a client who has a prescription for a wireless capsule
endoscopy. Which statement by the client would indicate to the nurse that the teaching was
effective? - CORRECT ANSWER-"I can go about my daily routine while the camera is passing
though my small intestine."
After data collection on a client, the nurse suspects that the client has diarrhea. Which data
collection finding, if observed by the nurse, would confirm the nurse's suspicion? - CORRECT
ANSWER-Hyperactive bowel sounds
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the
nurse provide about the purpose for this test? - CORRECT ANSWER-"This test detects heme, an
iron compound in blood within the stool."
The nurse is providing health teaching for four clients. Which client will the nurse teach that should
consider a colonoscopy screening? - CORRECT ANSWER-50-year-old client with a family history
of polyps
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place
set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and
manage the nasogastric tube? - CORRECT ANSWER-Disconnect the nasogastric tube from
suction during the assessment of bowel sounds.
A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed
to prompt a bowel movement. How should the nurse position the client in anticipation of
administering a cleansing enema? - CORRECT ANSWER-left side-lying
A nurse is caring for a client with constipation. The incidence of constipation tends to be high
among clients who follow which diet? - CORRECT ANSWER-a diet lacking in fruits and
vegetables
A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What
is the outcome of the use of cottonseed? - CORRECT ANSWER-lubricates and softens stool
A client has completed an upper gastrointestinal x-ray, small bowel series, and lower
gastrointestinal x-ray. Following these x-rays, the nurse will need to administer: - CORRECT
ANSWER-a laxative.
The nurse is educating a new colostomy client on gas-producing foods. Which food is a
gas-producing food the client may choose to avoid? - CORRECT ANSWER-brussels sprouts
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