Nokea
A nurse in a long-term care facility is assessing a group of patients. In which patients would the nurse anticipate increased risk for developing diarrhea? Select all that apply.
- A. Patient taking opioids for pain
- B. Patient taking metformin for type 2 diabetes
- C. Patient taking diuretics
- D. Patient who developed dehydration
- E. Patient taking amoxicillin clavulanate for infection
- F. Patient taking magnesium-containing antacids
Correct Answer: B,E,F
Rationale: Diarrhea is a side effect of metformin (B), amoxicillin clavulanate (E), and magnesium-containing antacids (F). Opioids (A), diuretics (C), and dehydration (D) are more likely to cause constipation.
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A nurse working on a GI unit is caring for a group of patients. In patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes? Select all that apply.
- A. Peritonitis
- B. Prolonged bedrest
- C. Diarrhea
- D. Gastroenteritis
- E. Early bowel obstruction
- F. Postoperative paralytic ileus
Correct Answer: A,B,F
Rationale: Decreased or absent bowel sounds indicate reduced motility, common in peritonitis (A), prolonged bedrest (B), and paralytic ileus (F). Diarrhea (C), gastroenteritis (D), and early bowel obstruction (E) typically cause hyperactive bowel sounds due to increased motility.
A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
- A. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
- B. Percussing all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen
- C. Lightly palpating over the abdominal quadrants; first checking for any areas of pain or discomfort
- D. Deeply palpating over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses
Correct Answer: A
Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation (A) follows inspection because palpation may alter bowel sounds. Percussion (B) and palpation (C, D) come later to avoid disturbing peristalsis.
For a patient with which health problem or issue would a nurse expect the health care provider to order colostomy irrigation?
- A. IBS
- B. Left-sided end colostomy in the sigmoid colon
- C. Postradiation damage to the bowel
- D. Crohn disease
Correct Answer: B
Rationale: Colostomy irrigation is indicated for left-sided end colostomies in the sigmoid colon (B) to promote regular evacuation. IBS (A), postradiation damage (C), and Crohn disease (D) are contraindications due to bowel instability.
A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse's first action in this situation?
- A. Reassuring the patient that this is a normal with a new ostomy
- B. Notifying the health care provider that the stoma is prolapsed
- C. Having the patient rest for 30 minutes to see if the prolapse resolves
- D. Replacing the appliance with a larger appliance
Correct Answer: C
Rationale: A protruding stoma suggests prolapse; the first action is having the patient rest for 30 minutes (C) to see if it resolves. Reassuring (A) is incorrect as prolapse isn't normal, notifying the provider (B) is premature, and a larger appliance (D) doesn't address the issue.
A nurse caring for a patient who reports frequent constipation learns the patient uses phosphate and sodium citrate enemas several times weekly. What education would the nurse provide?
- A. Avoid consuming fiber or roughage in the diet.
- B. Sedentary activities will be helpful.
- C. These enemas should be avoided with kidney failure.
- D. Restrict your fluids to 1,000 mL daily.
Correct Answer: C
Rationale: Phosphate and sodium citrate enemas (C) are contraindicated in kidney failure due to risk of hyperphosphatemia. Fiber (A) promotes regularity, activity (B) aids peristalsis, and fluid restriction (D) worsens constipation.