AND 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. - ANS 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 - ANS C
If the solution is too cold or the flow rate too fast, severe cramping may result.
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,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 - ANS 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 - ANS 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.
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, 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 - ANS 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." - ANS 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.
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