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A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse they are feeling dizzy and nauseated and then vomits. What should be the nurse's next action?
- A. Reassuring the patient that this is a normal reaction to the procedure
- B. Stopping the procedure, preparing to administer CPR, and notifying the primary care provider
- C. Stopping the procedure, assessing vital signs, and notifying the health care provider
- D. Pausing the procedure, waiting 5 minutes, and then resuming the procedure
Correct Answer: C
Rationale: Dizziness, nausea, and vomiting suggest vagal stimulation. Stopping the procedure, assessing vital signs, and notifying the provider (C) is appropriate. Reassuring (A) ignores the risk, CPR (B) is premature, and resuming after 5 minutes (D) is unsafe without assessment.
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A nurse is planning a bowel program for a patient with frequent constipation after sustaining a spinal cord injury. What is the first step the nurse will take?
- A. Offering a diet that is low in residue
- B. Increasing fluid intake to 3,000 mL daily
- C. Administering daily enemas to stimulate peristalsis
- D. Assessing the patient's bowel patterns
Correct Answer: D
Rationale: The first step is assessing bowel patterns (D) to understand frequency, consistency, and triggers, following the nursing process. Diet (A), fluids (B), and enemas (C) are interventions based on assessment findings.
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 asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
- A. This test replaces the need for screening colonoscopy.
- B. We are looking for infectious organisms in your stool.
- C. The screening assesses for blood in your stool.
- D. This test assesses for antibodies to colon cancer.
Correct Answer: C
Rationale: The guaiac test (C) detects occult blood in stool, screening for GI bleeding or cancer. It doesn't replace colonoscopy (A), detect organisms (B), or assess antibodies (D).
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. Eat dark-green vegetables to control the odor of the stool.
- F. You may have a tendency to develop food blockages.
Correct Answer: D,E,F
Rationale: Ileostomy stool is liquid (D), dark-green vegetables reduce odor (E), and food blockages are a risk (F). The stoma should be pink/red, not purple-blue (A), stabilizes in 4-6 weeks, not 2 (B), and skin should be clean and dry, not moist (C).
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.