Quiz 85: Bowel Elimination and Gastric Intubation
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
Instructor Verified Answers Included
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1. The nurse is caring for a patient who has been on bed rest for several weeks. The nurse notes that the patient is continually seeping liquid stool rectally. The nurse should take which action?
a. Hold the patient’s antibiotics.
b. Put the patient on a bran diet.
c. Perform a digital rectal examination.
d. Increase the dosage of the patient’s antibiotics.
2. The patient is a 74-year-old man who has been in the hospital for 4 days following an orthopedic surgical procedure. He is concerned because he has not moved his bowels every day as he did before surgery, but every other day. Which response made by the nurse is appropriate?
a. Advise the patient to put himself on over-the-counter laxatives.
b. Instruct the patient that daily bowel movements are not always necessary.
c. Educate the patient that with increasing age, his bowel movements should increase in frequency.
d. Inform the patient that he will call to get a laxative to get him back on track.
3. The nurse assesses that a patient has a severe fecal impaction. Which action taken by the nurse addresses this problem?
a. Administering laxatives
b. Providing a high-fiber diet
c. Performing a digital removal
d. Administering an enema
4. The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this procedure, the nurse should assess the patient history for which condition?
a. Heart disease
b. Abdominal pain
c. Urinary infection
d. Diabetes mellitus
5. When evaluating a student nurse’s ability to digitally remove feces, the nurse preceptor determined that further teaching is required if the student nurse does which of the following interventions?
a. Provides perianal skin care.
b. Continues the procedure if bleeding starts.
c. Follows the procedure by offering the patient the bedpan.
d. Discontinues the procedure in the presence of bradycardia.
6. The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload?
a. Hypertonic solution
c. Tap water
d. Harris flush
7. When preparing an infant for an enema, the nurse understands that which solution is the safest?
a. Tap-water enema solution
b. Hypertonic enema solution
c. Oil retention
d. Physiological normal saline
8. The patient is being prepped for surgery and has an order for “enemas until clear.” The nurse realizes that she will be giving a maximum of how many enemas?
9. The nurse is preparing to administer an enema to an adult patient who has normal sphincter control. For administration of the enema, the patient is placed in which position?
a. Right side-lying
b. Dorsal recumbent
10. The nurse has been directed to provide an enema for an elderly female patient who has very poor rectal sphincter control. Which position is most appropriate for this patient?
a. Sims’ position
b. Dorsal recumbent position on the bedpan
c. Sitting on the toilet
d. Right lateral position
11. When preparing an adult patient for an enema, the nurse understands that the tube or nozzle should be inserted how far?
a. 1 to inches
b. 2 to 3 inches
c. 3 to 4 inches
d. 4 to 5 inches
12. While the nurse is administering an enema with a standard enema bag, which intervention is important to implement?
a. Keeping the solution at room temperature
b. Positioning the patient on the right side
c. Raising the enema bag to 12 inches above the patient
d. Instructing the patient to release the enema solution as soon as possible
13. While the nurse is administering an enema, the patient complains of some cramping. Which action should the nurse take next?
a. Discontinue the procedure completely.
b. Increase the height of the solution.
c. Slow the rate of infusion.
d. Have the patient roll into a supine position.
14. When providing care for a patient who is disoriented during a nasogastric (NG) tube placement, which intervention is important for the nurse to implement?
a. Halt the procedure.
b. Request assistance with insertion.
c. Administer a hypnotic medication.
d. Continue the procedure as with any other patient.
15. When developing a plan of care for a patient requiring a nasogastric (NG) tube, the nurse recognizes that it is essential to implement which technique in measuring the length of the tube?
a. Measure from the nose to the ear to the patient’s navel.
b. Measure from the nose to the middle of the sternum.
c. Measure and mark a point 30 inches from the end.
d. Mark the 50-cm point on the tube, measure in the traditional way, and insert halfway between the two spots.
16. In advancing the nasogastric (NG) tube, which technique provides the safest outcome?
a. Rotate the tube if resistance is felt.
b. Advance the tube in between swallows.
c. Start with the patient’s head flexed.
d. Check the tube placement by instilling air and auscultating over the stomach.
17. When care is provided for a patient with an NG tube in place, which intervention is safest for the nurse to implement?
a. Tape the tube up and around the ear on the side of insertion.
b. Secure the tubing to the bed by the patient’s head.
c. Mark the tube where it exits the nose.
d. Change the tubing daily.
1. A patient is admitted for constipation. When planning care for this patient, the nurse recognizes that which interventions would help control constipation? (Select all that apply.)
a. Increases in activity level
b. Elimination of laxative use
c. Decreased dietary fiber
d. Increased fluids
e. Timely response to urge to move bowels
2. The patient is receiving a soapsuds enema but is having a difficult time retaining the fluid. What action should the nurse take? (Select all that apply.)
a. Give the enema slowly.
b. Place the patient in the dorsal recumbent position on a bedpan.
c. Give the enema with the patient on the toilet.
d. Give the enema in the right lateral position.
e. Give the enema faster.
3. The Levin tube and the Salem sump tube are used most commonly for stomach decompression. Which of the following statements about these tubes is true? (Select all that apply.)
a. Levin tubes have a blue “pigtail” that functions as an air vent.
b. These tubes are inserted as a sterile procedure.
c. The blue air vent should not be used for irrigation.
d. The Salem sump tube has a blue “pigtail” that functions as an air vent.
e. The Salem sump is preferred for stomach decompression.
4. What should the nurse do to verify nasogastric (NG) tube placement? (Select all that apply.)
a. Ask the patient to speak.
b. Inspect the posterior pharynx.
c. Aspirate back on the syringe.
d. Obtain an x-ray of the placement.
e. Auscultate the lung fields.
1. Infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces are signs of ________________.
2. __________________ is strongest during the hour after the first meal of the day.
3. A bedpan that is designed for patients with body or leg casts or for patients restricted from raising their hips (e.g., following total joint replacement) is known as a _____________.
4. _____________ is defined by a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate.
5. The inability to pass a hard collection of stool is known as ______________.
6. An ___________ is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.