Nokea
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.
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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 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 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 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.