Chapter 47: Bowel Elimination
MULTIPLE CHOICE
1. The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract
absorbs most of the nutrients?
a. Ileum
b. Cecum
c. Stomach
d. Duodenum
ANS: D
The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron,
and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.
DIF: Understand (comprehension)
OBJ: Discuss the role of gastrointestinal organs in digestion and elimination.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
2. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?
a. Sigmoid
b. Transverse
c. Ascending
d. Descending
ANS: C
The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid;
therefore, the least formed stool (very liquid) would be in the ascending.
DIF: Apply (application)
OBJ: Explain the physiological aspects of normal defecation. TOP: Assessment
MSC: Physiological Adaptation
3. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with
the first portion?
a. Cecum, ascending, transverse, descending, sigmoid, and rectum
b. Ascending, transverse, descending, sigmoid, rectum, and cecum
c. Cecum, sigmoid, ascending, transverse, descending, and rectum
d. Ascending, transverse, descending, rectum, sigmoid, and cecum
ANS: A
The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The
large intestine is the primary organ of bowel elimination.
DIF: Understand (comprehension)
OBJ: Discuss the role of gastrointestinal organs in digestion and elimination.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
4. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)?
a. Performing the first postoperative pouch change
b. Maintaining a nasogastric tube
c. Administering an enema
d. Digitally removing stool
ANS: C
The skill of administering an enema can be delegated to an AP. The skill of inserting and maintaining a nasogastric (NG) tube
cannot be delegated to an AP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be
delegated to nursing assistive personnel.
DIF: Apply (application)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Planning MSC: Management of Care
5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the
nurse recommend?
a. Broccoli and cheese soup with potato bread
b. Turkey and mashed potatoes with brown gravy
c. Grape and walnut chicken salad sandwich on whole wheat bread
d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
ANS: C
Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain
as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains,
fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down
peristalsis, causing constipation.
DIF: Apply (application)
OBJ: List nursing interventions that promote normal elimination.
TOP: Implementation MSC: Health Promotion and Maintenance
Copyright © 2021, Elsevier Inc. All rights reserved. 2
6. A patient is using laxatives 3 times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and
wonders if laxatives should be taken again. Which information will the nurse share with the patient?
a. Long-term laxative use causes the bowel to become less responsive to stimuli, and
constipation may occur.
b. Laxatives can cause trauma to the intestinal lining and scarring may result,
leading to decreased peristalsis.
c. Long-term use of emollient laxatives is effective for treatment of chronic
constipation and may be useful in certain situations.
d. Laxatives cause the body to become malnourished, so when the patient begins
eating again, the body absorbs all of the food, and no waste products are
produced.
ANS: A
Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response
to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel
function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the
body will produce waste if any substance is consumed.
DIF: Understand (comprehension)
OBJ: Discuss psychological and physiological factors that influence the elimination process.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
7. A patient recovering from a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse
will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema
b. Withholding narcotic pain medication
c. Administering laxatives to the patient
d. Raising the head of the bed
ANS: D
Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper
contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a
diagnostic test, not an intervention to promote defecation. Pain-relief measures should be given; however, preventative action
should be taken to prevent constipation.
DIF: Apply (application)
OBJ: Discuss psychological and physiological factors that influence the elimination process.
TOP: Implementation MSC: Basic Care and Comfort
8. Which patient is most at risk for increased peristalsis?
a. A 5-year-old child who ignores the urge to defecate owing to embarrassment
b. A 21-year-old female with three final examinations on the same day
c. A 40-year-old female with major depressive disorder
d. An 80-year-old male in an assisted-living environment
ANS: B
Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the
urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from
slowed peristalsis.
DIF: Apply (application)
OBJ: Describe common physiological alterations in elimination.
TOP: Assessment MSC: Psychosocial Integrity
9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most
appropriate?
a. “This is probably a false negative; we should rerun the test.”
b. “You should schedule a colonoscopy as soon as possible.”
c. “Are you under a lot of stress?”
d. “Do you take iron supplements?”
ANS: D
Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is
negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable
test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse’s initial priority.
Stress alters GI motility and stool consistency, not color.
DIF: Analyze (analysis)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Implementation MSC: Health Promotion and Maintenance
Copyright © 2021, Elsevier Inc. All rights reserved. 3
10. Which patient will the nurse assess most closely for an ileus?
a. A patient with a fecal impaction
b. A patient with chronic cathartic abuse
c. A patient with surgery for bowel disease and anesthesia
d. A patient with suppression of hydrochloric acid from medication
ANS: C
Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of
peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to
suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive.
DIF: Apply (application)
OBJ: Describe common physiological alterations in elimination.
TOP: Assessment MSC: Management of Care
11. A patient is experiencing a fecal impaction. Which portion of the colon will the nurse assess?
a. Descending
b. Transverse
c. Ascending
d. Rectum
ANS: D
A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved
constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and
descending colon still consist mostly of liquid and do not form a hardened mass.
DIF: Apply (application) OBJ: Assess a patient’s elimination pattern.
TOP: Assessment MSC: Basic Care and Comfort
12. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?
a. A 25-year-old patient with diarrhea
b. A 30-year-old patient with Clostridium difficile
c. A 40-year-old patient with an ileostomy
d. A 70-year-old patient with stool incontinence
ANS: D
The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training,
also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no
method can be used to set up a schedule of elimination.
DIF: Analyze (analysis)
OBJ: List nursing interventions included in bowel training. TOP: Implementation
MSC: Basic Care and Comfort
13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?
a. Administer a soapsuds enema every 2 hours.
b. Use a mobility device to place the patient on a bedside commode.
c. Give the patient a pillow to brace against the abdomen while bearing down.
d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on
bedpan.
ANS: B
The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a
mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer
to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the
best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds
enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.
DIF: Apply (application)
OBJ: List nursing interventions that promote normal elimination.
TOP: Implementation MSC: Basic Care and Comfort
14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome
will the nurse evaluate as successful for the patient to establish normal defecation?
a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patient’s lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds in all four quadrants.
ANS: A
The nurse’s goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and
formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates
constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication
of defecation.
DIF: Apply (application)
OBJ: List nursing diagnoses related to alterations in elimination.
TOP: Evaluation MSC: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved. 4
15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
a. Liquid consistency of stool
b. Presence of blood in the stool
c. Malodorous stool
d. Continuous output from the stoma
ANS: B
Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for
an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous.
DIF: Analyze (analysis)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Assessment MSC: Management of Care
16. The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
a. Ultrasound
b. Barium enema
c. Endoscopy
d. Anorectal manometry
ANS: C
Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other
option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization.
DIF: Apply (application)
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.
TOP: Planning MSC: Management of Care
17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too
large for the patient to pass voluntarily. Which is the next priority nursing action?
a. Preparing the patient for a second tap water enema
b. Obtaining an order for digital removal of stool
c. Positioning the patient on the left side
d. Inserting a rectal tube
ANS: B
When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the
anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left
side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be
applicable or effective for this patient.
DIF: Apply (application)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Implementation MSC: Basic Care and Comfort
18. A nurse is checking orders. Which order should the nurse question?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema for a patient with fluid volume excess
c. A Kayexalate enema for a patient with severe hypokalemia
d. An oil retention enema for a patient with constipation
ANS: C
Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low
potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended
for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Oil retention enemas lubricate
the feces in the rectum and colon and are used for constipation.
DIF: Analyze (analysis)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Implementation MSC: Management of Care
19. The nurse performing a fecal occult blood test should take what action?
a. Test the quality control section before testing the stool specimens.
b. Apply liberal amounts of stool to the guaiac paper.
c. Report a positive finding to the provider.
d. Don sterile disposable gloves.
ANS: C
Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean
procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be
developed after it is determined whether the sample is positive or negative.
DIF: Apply (application)
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.
TOP: Implementation MSC: Reduction of Risk Potential
Copyright © 2021, Elsevier Inc. All rights reserved. 5
20. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination
b. Administering a colon cleansing product 6 hours before the examination
c. Obtaining an order for a pain medication before the test is performed
d. Removing all of the patient’s metallic jewelry
ANS: D
No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the
machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs.
Pain medication is not needed before the examination is performed.
DIF: Apply (application)
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.
TOP: Implementation MSC: Reduction of Risk Potential
21. A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting
with the first one?
1. Obtain baseline vital signs.
2. Apply clean gloves and lubricate.
3. Insert index finger into the rectum.
4. Identify patient using two identifiers.
5. Place patient on left side in Sims’ position.
6. Massage around the feces and work down to remove.
a. 4, 1, 5, 2, 3, 6
b. 1, 4, 2, 5, 3, 6
c. 4, 1, 2, 5, 3, 6
d. 1, 4, 5, 2, 3, 6
ANS: A
The steps for removing a fecal impaction are as follows: identify patient using two identifiers, obtain baseline vital signs, place on
left side in Sims’ position, apply clean gloves and lubricate, insert index finger into the rectum, and gently loosen the fecal mass by
massaging around it and work the feces downward toward the end of the rectum.
DIF: Understand (comprehension)
OBJ: List nursing interventions that promote normal elimination.
TOP: Implementation MSC: Basic Care and Comfort
22. Before being administered a cleansing enema an 80-year-old patient says “I don’t think I will be able to hold the enema.” Which is
the next priority nursing action?
a. Rolling the patient into right-lying Sims’ position
b. Positioning the patient in the dorsal recumbent position on a bedpan
c. Inserting a rectal plug to contain the enema solution after administering
d. Assisting the patient to the bedside commode and administering the enema
ANS: B
If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients
with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the
toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the
fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims’ position will not help the
patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe.
DIF: Apply (application)
OBJ: List nursing interventions that promote normal elimination.
TOP: Implementation MSC: Management of Care
23. A nurse is providing care to a group of patients. Which patient will the nurse see first?
a. A child about to receive a normal saline enema
b. A teenager about to receive loperamide for diarrhea
c. A dehydrated older patient about to receive a hypertonic enema
d. A middle-aged patient with myocardial infarction about to receive docusate
sodium
ANS: C
A hypertonic enema is contradicted in a dehydrated patient since it will pull fluid out of the body; this patient should be seen first.
All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given
for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining.
DIF: Analyze (analysis)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Assessment MSC: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved. 6
24. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression?
a. Salem sump
b. Small bore
c. Levin
d. 8 Fr
ANS: A
The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric
contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free,
continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes
near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fineor small-bore tubes are frequently used for medication administration and enteral feedings.
DIF: Apply (application)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Planning MSC: Management of Care
25. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition
of the new ostomy?
a. Eggs over easy, whole wheat toast, and orange juice with pulp
b. Chicken fried rice with fresh pineapple and iced tea
c. Turkey sandwich on whole wheat bread and iced tea
d. Fish sticks with sweet corn and soda
ANS: C
Patients with colostomies have no diet restrictions other than the diet discussed for normal healthy bowel function, with adequate
fiber and fluid to keep the stool softly formed. Fried foods can irritate digestion. Foods high in fiber will be useful later in the
recovery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with
indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cabbage could cause this problem.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Implementation MSC: Physiological Adaptation
26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate?
a. Changing the skin barrier portion of the ostomy pouch daily
b. Emptying the pouch at least once every 7 days.
c. Thoroughly cleansing the skin around the stoma with soap and water to remove
excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a 1/2-inch space
around the stoma
ANS: B
The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be
gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which
may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the
effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Implementation MSC: Physiological Adaptation
27. The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take?
a. Instill solution into pigtail slowly.
b. Check placement after instillation of solution.
c. Immediately aspirate after instilling fluid.
d. Prepare 60 mL of tap water into Asepto syringe.
ANS: C
After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue
“pigtail” air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of
irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach
fluids.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Implementation MSC: Physiological Adaptation
28. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect?
a. Reports decreased diarrhea.
b. Experiences pain relief.
c. Has a bowel movement.
d. Passes flatulence.
ANS: C
A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The
other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications
will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence).
DIF: Analyze (analysis)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Evaluation MSC: Pharmacological and Parenteral Therapies
Copyright © 2021, Elsevier Inc. All rights reserved. 7
29. An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what
should the nurse do?
a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
b. Tape an occlusive moisture barrier pad to the patient’s skin.
c. Apply a skin protective ointment after perineal care.
d. Massage the skin with light kneading pressure.
ANS: C
Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and
occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.
DIF: Apply (application)
OBJ: List nursing interventions that promote normal elimination.
TOP: Implementation MSC: Basic Care and Comfort
30. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric
tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours.
ANS: C
The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble
lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat,
not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Implementation MSC: Basic Care and Comfort
31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient
indicates the need for further education?
a. “If I get a blue color that means the test is negative.”
b. “I should not get any urine on the stool I am testing.”
c. “If I eat red meat before my test, it could give me false results.”
d. “I should check with my doctor to stop taking aspirin before the test.”
ANS: A
A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this
misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not
contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care
provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be
instructed to stop taking aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs for 7 days because these could
cause a false-positive test result.
DIF: Apply (application)
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.
TOP: Evaluation MSC: Reduction of Risk Potential
32. A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain?
a. Ewald
b. Dobhoff
c. Miller-Abbott
d. Sengstaken-Blakemore
ANS: A
Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin,
Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated
balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric
decompression.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Planning MSC: Management of Care
33. The nurse is caring for a patient diagnosed with C. difficile. Which nursing actions will have the greatest impact in preventing the
spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly inservices about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques
ANS: D
Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly inservices place
emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in
contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.
DIF: Apply (application)
OBJ: Discuss psychological and physiological factors that influence the elimination process.
TOP: Implementation MSC: Safety and Infection Control
Copyright © 2021, Elsevier Inc. All rights reserved. 8
34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other
assessment finding?
a. Hypoactive bowel sounds
b. Increased fluid intake
c. Soft tender abdomen
d. Jaundice in sclera
ANS: A
Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive
bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a
decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease.
DIF: Apply (application) OBJ: Assess a patient’s elimination pattern.
TOP: Assessment MSC: Physiological Adaptation
35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect?
a. Distended abdomen
b. Increased skin dryness
c. Increased energy levels
d. Elevated blood pressure
ANS: B
Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with dark colored urine and dry skin.
Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen could indicate
constipation.
DIF: Apply (application) OBJ: Assess a patient’s elimination pattern.
TOP: Assessment MSC: Physiological Adaptation
36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding
immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.
ANS: C
A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma
should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.
DIF: Apply (application)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Assessment MSC: Management of Care
37. A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve?
a. Prevent gaseous distention.
b. Prevent constipation.
c. Prevent colon infection.
d. Prevent lower bowel inflammation.
ANS: C
A medicated enema is a neomycin solution, that is, an antibiotic used to reduce bacteria in the colon before bowel surgery.
Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathartics
help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the
lower colon.
DIF: Apply (application)
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP: Planning MSC: Basic Care and Comfort
38. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient’s stool?
a. Bright red blood
b. Dark black blood
c. Microscopic
d. Mucoid
ANS: C
Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic).
This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood,
and blood that contains mucus (mucoid) is not the purpose of a guaiac test.
DIF: Understand (comprehension)
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract.
TOP: Assessment MSC: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved. 9
39. A patient is receiving opioids for pain. Which bowel assessment is a priority?
a. C. difficile
b. Constipation
c. Hemorrhoids
d. Diarrhea
ANS: B
Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. Clostridium
difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as
frequently as constipation.
DIF: Apply (application) OBJ: Assess a patient’s elimination pattern.
TOP: Assessment MSC: Pharmacological and Parenteral Therapies
40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy?
a. Keep fiber low.
b. Eat large meals.
c. Increase fluid intake.
d. Chew food thoroughly.
ANS: C
Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be
sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they
empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A
low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority;
liquid is the priority.
DIF: Analyze (analysis)
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP: Teaching/Learning MSC: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.)
a. Record times when the patient is incontinent.
b. Help the patient to the toilet at the designated time.
c. Lean backward on the hips while sitting on the toilet.
d. Maintain normal exercise within the patient’s physical ability.
e. Apply pressure with hands over the abdomen, and strain while pushing.
f. Choose a time based on the patient’s pattern to initiate defecation-control
measures.
ANS: A, B, D, F
A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is
incontinent. Choosing a time based on the patient’s pattern to initiate defecation-control measures. Maintaining normal exercise
within the patient’s physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit
juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the
patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear
down but do not strain to stimulate colon emptying.
DIF: Understand (comprehension)
OBJ: List nursing interventions included in bowel training. TOP: Implementation
MSC: Health Promotion and Maintenance
2. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session?
(Select all that apply.)
a. A risk factor is smoking.
b. A risk factor is high intake of animal fats or red meat.
c. A warning sign is rectal bleeding.
d. A warning sign is a sense of incomplete evacuation.
e. Screening with a colonoscopy is every 5 years, starting at age 50.
f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50.
ANS: A, B, C, D
Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and
heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of
incomplete evacuation, and unexplained abdominal or back pain. A flexible sigmoidoscopy is every 5 years, starting at age 50,
while a colonoscopy is every 10 years, starting at age 50.
DIF: Understand (comprehension)
OBJ: Describe common physiological alterations in elimination.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance