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A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) an upper GI series. What is the correct order for performing the tests?
- A. c, b, d, a
- B. d, c, a, b
- C. a, b, d, c
- D. b, a, d, c
Correct Answer: D
Rationale: Fecal occult blood test (b) comes first to detect bleeding, followed by barium enema (a), upper GI series (d), and endoscopic studies (c) to avoid barium interference and prioritize non-invasive tests (D).
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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 caring for a patient who had abdominal surgery and has a nasogastric tube attached to low suction. Which nursing actions are appropriate when caring for this patient? Select all that apply.
- A. Irrigating the tube with 30-mL normal saline solution
- B. Confirming tube placement via pH testing of gastric secretions
- C. Positioning the air vent at the level of the patient's umbilicus
- D. Instilling irrigation via the blue air vent
- E. Monitoring the patient's abdomen for distention
- F. Documenting the nasogastric irrigation and drainage with I & O
Correct Answer: A,B,E,F
Rationale: Appropriate actions include irrigating with saline (A), confirming placement via pH (B), monitoring for distention (E), and documenting I&O (F). The air vent should be above the stomach, not at the umbilicus (C), and irrigation goes through the main lumen, not the air vent (D).
A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
- A. Administering a large volume of solution (500 to 1,000 mL)
- B. Mixing milk and molasses in equal parts for an enema
- C. Instructing the patient to retain the enema for at least 30 minutes
- D. Administering the enema while the patient is sitting on the toilet
Correct Answer: C
Rationale: Retention enemas require the patient to hold the solution for at least 30 minutes (C) to soften stool. Large volumes (A) are for cleansing enemas, milk and molasses (B) are for carminative enemas, and administering on the toilet (D) prevents retention.
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 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.