Nokea
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.
You may also like to solve these questions
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.
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 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).
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 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.