Guide Questions And Answers 2025
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