NSG 1520 FINAL EXAM PART 2 | SOUTH COLLEGE |
QUESTIONS WITH VERIFIED 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 in 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. - Answers - a. The sequence for abdominal
assessment proceeds from inspection, auscultation, percussion, and then palpation.
Inspection and auscultation are performed before palpation because palpation may
disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually
performed by advanced practice professionals.
A nurse is administering a large-volume cleansing enema to a patient prior to surgery.
Once the enema solution is introduced, the patient reports severe cramping. What
nursing intervention would the nurse perform next based on this patient reaction?
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 primary care provider. - Answers - c. If the
patient reports severe cramping with introduction of an enema solution, the nurse
should lower the solution container and check the temperature and flow rate. If the
solution is too cold or the flow rate too fast, severe cramping may occur. The head of
the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be
placed on a bedpan in the supine position while receiving the enema.
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 - Answers - a, b, f. Decreased or
absent bowel sounds—evidenced only after listening for 5 minutes (Hogan-Quigley,
,Palm, & Bickley, 2017)—signify the absence of bowel motility, commonly associated
with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds
indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early
bowel obstruction.
A nurse assesses the stool of patients who are experiencing gastrointestinal 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 metformin for type 2 diabetes mellitus
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 over-the-counter antacids - Answers - b, e, f. Diarrhea is a potential
adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter
antacids. Narcotics, diuretics, and dehydration may lead to constipation.
A patient has a fecal impaction. Which nursing action is correctly performed when
administering an oil-retention enema for this patient?
A. The nurse administers a large volume of solution (500 to 1,000 mL)
B. The nurse mixes milk and molasses in equal parts for an enema
C. The nurse instructs the patient to retain the enema for at least 30 minutes
D. The nurse administers the enema while the patient is sitting on the toilet - Answers -
c. The patient should be instructed to retain the enema solution for at least 30 minutes
or as indicated in the manufacturer's instructions. The usual amount of solution
administered with a retention enema is 150 to 200 mL for an adult. The milk and
molasses mixture is a carminative enema that helps to 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 a 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." - Answers - d, e, f.
Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the
intake of dark-green vegetables because they contain chlorophyll, which helps to
deodorize the feces. Patients with 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 usually stabilizes within 4
to 6 weeks, and the skin around the stoma site (peristomal area) 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 low-fiber diet several days before the test.
B. Have the patient take bisacodyl 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. - Answers -
a. If possible, a low-residue diet (low fiber) should be followed several days before the
procedure. Most will maintain the low-residue diet; others may have full liquid diet the
day before the procedure. There are multiple types of bowel preps for this procedure.
The provider performing the procedure will decide which is best for the individual
patient.
The prep is usually given as a split dose, with half being given the night before and rest
the morning of the procedure. It is recommended the second dose be given at least 5
hours and completed at least 2 hours before the study. There are some who may
receive the prep the same day as the procedure, especially if the procedure is
scheduled for later in the day.
Conscious sedation, not general anesthesia, will be given for the colonoscopy. A
chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal
and small-bowel series of tests.
A nurse is performing digital removal of stool on a patient with a fecal impaction. During
the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then
vomits. What should be the nurse's next action?
A. Reassure the patient that this is a normal reaction to the procedure.
B. Stop the procedure, prepare to administer CPR, and notify the primary care provider.
C. Stop the procedure, assess vital signs, and notify the primary care provider.
D. Stop the procedure, wait 5 minutes, and then resume the procedure. - Answers - c.
When a patient reports dizziness or lightheadedness and has nausea and vomiting
during digital stool removal, the nurse should stop the procedure, assess heart rate and
blood pressure, and notify the health care provider. The vagus nerve may have been
stimulated.
A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The
health care provider ordered the following tests: (a) barium enema, (b) fecal occult
blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the
correct order in which the tests would normally be performed?
A. c, b, d, a
B. d, c, a, b
C. a, b, d, c
D. b, a, d, c - Answers - d. A fecal occult blood test should be done first to detect
gastrointestinal bleeding. Barium studies should be performed next to visualize
gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or
other lesions. A barium enema and routine radiography should precede an upper
gastrointestinal series because retained barium from an upper gastrointestinal series
could take several days to pass through the gastrointestinal tract and cloud anatomic
detail on the barium enema studies. Noninvasive procedures usually take precedence
, over invasive procedures, such as endoscopic studies, when sufficient diagnostic data
can be obtained from them.
A nurse is caring for a patient who has an NG tube in place for gastric decompression.
Which nursing actions are appropriate when irrigating an NG tube connected to
suction? Select all that apply.
A. Draw up 30 mL of saline solution into the syringe.
B. Unclamp the suction tubing near the connection site to instill solution.
C. Place the tip of the syringe in the tube to gently insert saline solution.
D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
E. After instilling irrigant, hold the end of the NG tube over an irrigation tray.
F. Observe for return flow of NG drainage into an available container. - Answers - a, c,
e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of
saline solution (or the amount indicated in the order or policy) into the syringe, clamp
the suction tubing near the connection site to protect the patient from leakage of NG
drainage, place the tip of the syringe in the tube to gently insert the saline solution, then
place the syringe in the drainage port, not in the blue air vent of a Salem sump or
double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach
when the Salem sump is attached to suction). After instilling irrigant, hold the end of the
NG tube over an irrigation tray or emesis basin, and observe for return flow of NG
drainage into an available container.
A nurse is planning a bowel-training program for a patient with frequent constipation.
What is a recommended intervention?
A. Using a diet that is low in bulk
B. Decreasing fluid intake to 1,000 mL
C. Administering an enema once a day to stimulate peristalsis
D. Monitoring bowel movements - Answers - d. For a bowel-training program to be
effective, the nurse should monitor bowel movements including frequency, consistency,
shape, volume and color, as appropriate, monitor bowel sounds, teach patient about
specific foods that are assistive in promoting bowel regularity, ensure privacy, and
encourage adequate fluid intake.
A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse
effect would the nurse monitor in this patient?
A. Incontinence
B. Constipation
C. Electrolyte imbalances
D. Infection - Answers - a. The outcomes for this IPAA surgery are not always ideal, and
many patients experience decreased quality of life due to frequent defecation and fecal
seepage and incontinence.
For which patient would a nurse expect the primary care provider to order colostomy
irrigation?
A. A patient with IBS
B. A patient with a left-sided end colostomy in the sigmoid colon
QUESTIONS WITH VERIFIED 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 in 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. - Answers - a. The sequence for abdominal
assessment proceeds from inspection, auscultation, percussion, and then palpation.
Inspection and auscultation are performed before palpation because palpation may
disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually
performed by advanced practice professionals.
A nurse is administering a large-volume cleansing enema to a patient prior to surgery.
Once the enema solution is introduced, the patient reports severe cramping. What
nursing intervention would the nurse perform next based on this patient reaction?
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 primary care provider. - Answers - c. If the
patient reports severe cramping with introduction of an enema solution, the nurse
should lower the solution container and check the temperature and flow rate. If the
solution is too cold or the flow rate too fast, severe cramping may occur. The head of
the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be
placed on a bedpan in the supine position while receiving the enema.
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 - Answers - a, b, f. Decreased or
absent bowel sounds—evidenced only after listening for 5 minutes (Hogan-Quigley,
,Palm, & Bickley, 2017)—signify the absence of bowel motility, commonly associated
with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds
indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early
bowel obstruction.
A nurse assesses the stool of patients who are experiencing gastrointestinal 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 metformin for type 2 diabetes mellitus
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 over-the-counter antacids - Answers - b, e, f. Diarrhea is a potential
adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter
antacids. Narcotics, diuretics, and dehydration may lead to constipation.
A patient has a fecal impaction. Which nursing action is correctly performed when
administering an oil-retention enema for this patient?
A. The nurse administers a large volume of solution (500 to 1,000 mL)
B. The nurse mixes milk and molasses in equal parts for an enema
C. The nurse instructs the patient to retain the enema for at least 30 minutes
D. The nurse administers the enema while the patient is sitting on the toilet - Answers -
c. The patient should be instructed to retain the enema solution for at least 30 minutes
or as indicated in the manufacturer's instructions. The usual amount of solution
administered with a retention enema is 150 to 200 mL for an adult. The milk and
molasses mixture is a carminative enema that helps to 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 a 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." - Answers - d, e, f.
Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the
intake of dark-green vegetables because they contain chlorophyll, which helps to
deodorize the feces. Patients with 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 usually stabilizes within 4
to 6 weeks, and the skin around the stoma site (peristomal area) 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 low-fiber diet several days before the test.
B. Have the patient take bisacodyl 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. - Answers -
a. If possible, a low-residue diet (low fiber) should be followed several days before the
procedure. Most will maintain the low-residue diet; others may have full liquid diet the
day before the procedure. There are multiple types of bowel preps for this procedure.
The provider performing the procedure will decide which is best for the individual
patient.
The prep is usually given as a split dose, with half being given the night before and rest
the morning of the procedure. It is recommended the second dose be given at least 5
hours and completed at least 2 hours before the study. There are some who may
receive the prep the same day as the procedure, especially if the procedure is
scheduled for later in the day.
Conscious sedation, not general anesthesia, will be given for the colonoscopy. A
chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal
and small-bowel series of tests.
A nurse is performing digital removal of stool on a patient with a fecal impaction. During
the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then
vomits. What should be the nurse's next action?
A. Reassure the patient that this is a normal reaction to the procedure.
B. Stop the procedure, prepare to administer CPR, and notify the primary care provider.
C. Stop the procedure, assess vital signs, and notify the primary care provider.
D. Stop the procedure, wait 5 minutes, and then resume the procedure. - Answers - c.
When a patient reports dizziness or lightheadedness and has nausea and vomiting
during digital stool removal, the nurse should stop the procedure, assess heart rate and
blood pressure, and notify the health care provider. The vagus nerve may have been
stimulated.
A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The
health care provider ordered the following tests: (a) barium enema, (b) fecal occult
blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the
correct order in which the tests would normally be performed?
A. c, b, d, a
B. d, c, a, b
C. a, b, d, c
D. b, a, d, c - Answers - d. A fecal occult blood test should be done first to detect
gastrointestinal bleeding. Barium studies should be performed next to visualize
gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or
other lesions. A barium enema and routine radiography should precede an upper
gastrointestinal series because retained barium from an upper gastrointestinal series
could take several days to pass through the gastrointestinal tract and cloud anatomic
detail on the barium enema studies. Noninvasive procedures usually take precedence
, over invasive procedures, such as endoscopic studies, when sufficient diagnostic data
can be obtained from them.
A nurse is caring for a patient who has an NG tube in place for gastric decompression.
Which nursing actions are appropriate when irrigating an NG tube connected to
suction? Select all that apply.
A. Draw up 30 mL of saline solution into the syringe.
B. Unclamp the suction tubing near the connection site to instill solution.
C. Place the tip of the syringe in the tube to gently insert saline solution.
D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
E. After instilling irrigant, hold the end of the NG tube over an irrigation tray.
F. Observe for return flow of NG drainage into an available container. - Answers - a, c,
e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of
saline solution (or the amount indicated in the order or policy) into the syringe, clamp
the suction tubing near the connection site to protect the patient from leakage of NG
drainage, place the tip of the syringe in the tube to gently insert the saline solution, then
place the syringe in the drainage port, not in the blue air vent of a Salem sump or
double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach
when the Salem sump is attached to suction). After instilling irrigant, hold the end of the
NG tube over an irrigation tray or emesis basin, and observe for return flow of NG
drainage into an available container.
A nurse is planning a bowel-training program for a patient with frequent constipation.
What is a recommended intervention?
A. Using a diet that is low in bulk
B. Decreasing fluid intake to 1,000 mL
C. Administering an enema once a day to stimulate peristalsis
D. Monitoring bowel movements - Answers - d. For a bowel-training program to be
effective, the nurse should monitor bowel movements including frequency, consistency,
shape, volume and color, as appropriate, monitor bowel sounds, teach patient about
specific foods that are assistive in promoting bowel regularity, ensure privacy, and
encourage adequate fluid intake.
A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse
effect would the nurse monitor in this patient?
A. Incontinence
B. Constipation
C. Electrolyte imbalances
D. Infection - Answers - a. The outcomes for this IPAA surgery are not always ideal, and
many patients experience decreased quality of life due to frequent defecation and fecal
seepage and incontinence.
For which patient would a nurse expect the primary care provider to order colostomy
irrigation?
A. A patient with IBS
B. A patient with a left-sided end colostomy in the sigmoid colon
