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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.
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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 is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
- A. Saline osmotic laxative
- B. Bulk-forming laxative
- C. Methylcellulose
- D. Stool softener
Correct Answer: A
Rationale: Saline osmotic laxatives (A) can cause fluid/electrolyte imbalances in older adults, especially with kidney or cardiac issues, and should be avoided. Bulk-forming (B, C) and stool softeners (D) are safer options.
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 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.
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.