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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.
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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.
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 preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
- A. Having the patient consume a low-fiber diet several days before the test
- B. Having the patient take bisacodyl and ingest a gallon oral polyethylene glycol solution (PEG)
- C. Preparing the patient for the use of general anesthesia during the test
- D. Explaining that barium contrast mixture will be given to drink before the test
Correct Answer: A
Rationale: A low-fiber diet several days before a colonoscopy (A) reduces residue in the colon. PEG is used, but bisacodyl (B) isn't standard for all preps. Conscious sedation, not general anesthesia (C), is typical, and barium (D) is for other GI tests.
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 is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
- A. Elevating the head of the bed 30 degrees and repositioning the rectal tube
- B. Placing the patient in a supine position and modifying the amount of solution
- C. Lowering the solution container and checking the temperature and flow rate
- D. Removing the rectal tube and notifying the primary care provider
Correct Answer: C
Rationale: Severe cramping during an enema suggests the solution is too cold or the flow rate is too fast. Lowering the container and checking temperature and flow rate (C) addresses this. Elevating the bed (A) or changing position (B) doesn't resolve cramping, and removing the tube (D) is premature.