Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition.

Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which action will the nurse include in the plan of care for a patient who is being admitted with Clost ...

Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used. ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile. DIF: Cognitive Level: Apply (application) REF: 932 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 2. A 74-yr-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary. ANS: B The nurse’s initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 933 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. DIF: Cognitive Level: Apply (application) REF: 935 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient’s symptoms? a. “What type of foods do you eat?” b. “Is it possible that you are pregnant?” c. “Can you tell me more about the pain?” d. “What is your usual elimination pattern?” ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient’s symptoms. DIF: Cognitive Level: Analyze (analysis) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the prescribed IV morphine sulfate. d. Offer the prescribed promethazine (Phenergan). ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention. DIF: Cognitive Level: Analyze (analysis) REF: 940 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient’s oral temperature. d. Obtain information about the accident. ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery. DIF: Cognitive Level: Analyze (analysis) REF: 941 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids. ANS: C The patient’s clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time. DIF: Cognitive Level: Apply (application) REF: 942 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms. ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS. DIF: Cognitive Level: Apply (application) REF: 940 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient’s oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery. ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. DIF: Cognitive Level: Apply (application) REF: 946 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. c. Ambulate six times daily. b. Monitor stools for blood. d. Increase dietary fiber intake. ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur. DIF: Cognitive Level: Apply (application) REF: 949 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 11. Which patient statement indicates that the nurse’s teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. “The medication will be tapered if I need surgery.” b. “I will need to use a sunscreen when I am outdoors.” c. “I will need to avoid contact with people who are sick.” d. “The medication prevents the infections that cause diarrhea.” ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed. DIF: Cognitive Level: Apply (application) REF: 947 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool. ANS: B Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool. DIF: Cognitive Level: Apply (application) REF: 950 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 13. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs c. Oatmeal with cream b. White toast and jam d. Pancakes with syrup ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 949 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, “I cannot manage all these changes. I don’t want to look at the stoma.” What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient. ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient’s feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient’s ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy. DIF: Cognitive Level: Analyze (analysis) REF: 959 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. A patient has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. c. enteral nutrition. b. fluid restriction. d. activity restrictions. ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. DIF: Cognitive Level: Apply (application) REF: 947 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. A young woman who has Crohn’s disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse. ANS: B Fistulas between the bowel and bladder occur in Crohn’s disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse. DIF: Cognitive Level: Apply (application) REF: 963 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. A patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. c. projectile vomiting. b. metabolic alkalosis. d. abdominal distention. ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction. DIF: Cognitive Level: Apply (application) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. The nurse preparing for the annual physical exam of a 50-yr-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing. ANS: B At age 50 years, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50 years. DIF: Cognitive Level: Apply (application) REF: 954 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 19. The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will begin sitting in a chair at the bedside on the first postoperative day. b. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. c. An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. The site where the stoma will be located will be marked on the abdomen preoperatively. ANS: D A WOCN should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria. DIF: Cognitive Level: Apply (application) REF: 960 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy. ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA. DIF: Cognitive Level: Understand (comprehension) REF: 955 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma. ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. DIF: Cognitive Level: Analyze (analysis) REF: 956 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22. A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings. ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. DIF: Cognitive Level: Apply (application) REF: 960 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin. ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. DIF: Cognitive Level: Apply (application) REF: 962 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 24. A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about cups daily. a. 2 c. 4 b. 3 d. 5 ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL. DIF: Cognitive Level: Understand (comprehension) REF: 958 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. prepare for colonoscopy. c. give stool softeners and enemas. d. order a diet high in fiber and fluids. ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis. DIF: Cognitive Level: Apply (application) REF: 964 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 26. A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling. ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain. DIF: Cognitive Level: Apply (application) REF: 965 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 27. Which breakfast choice indicates a patient’s good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese b. wheat toast with butter d. Corn tortilla with scrambled eggs ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do. DIF: Cognitive Level: Apply (application) REF: 967 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 28. After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed. ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean. DIF: Cognitive Level: Apply (application) REF: 969 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 29. A patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. c. schedule a barium enema. b. prepare for colonoscopy. d. have blood cultures drawn. ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. DIF: Cognitive Level: Apply (application) REF: 931 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 30. The nurse will plan to teach a patient with Crohn’s disease who has megaloblastic anemia about the need for a. iron dextran infusions b. oral ferrous sulfate tablets. c. routine blood transfusions. d. cobalamin (B12) supplements. ANS: D Crohn’s disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. DIF: Cognitive Level: Apply (application) REF: 946 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 31. The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. c. McBurney sign. b. Rovsing sign. d. Grey-Turner’s sign. ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner’s sign is bruising over the flanks. Deep tenderness at McBurney’s point (halfway between the umbilicus and the right iliac crest), known as McBurney’s sign, is a sign of acute appendicitis. DIF: Cognitive Level: Understand (comprehension) REF: 941 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 32. A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently. ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom. DIF: Cognitive Level: Apply (application) REF: 934 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 33. Which question from the nurse would help determine if a patient’s abdominal pain might indicate irritable bowel syndrome (IBS)? a. “Have you been passing a lot of gas?” b. “What foods affect your bowel patterns?” c. “Do you have any abdominal distention?” d. “How long have you had abdominal pain?” ANS: D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria. DIF: Cognitive Level: Apply (application) REF: 940 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 34. A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction. ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated. DIF: Cognitive Level: Analyze (analysis) REF: 947 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 35. A 25-yr-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility. ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 932 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 36. A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Draw a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer’s solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan. ANS: C The priority for this patient is to treat the patient’s hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. DIF: Cognitive Level: Analyze (analysis) REF: 939 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 37. Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient’s health care provider. c. check for tube placement and reposition it. d. remove the tube and replace it with a new one. ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded. DIF: Cognitive Level: Analyze (analysis) REF: 939 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 38. A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria. ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment. DIF: Cognitive Level: Apply (application) REF: 939 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 39. Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown. ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs. DIF: Cognitive Level: Apply (application) REF: 960 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 40. Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes. ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention. DIF: Cognitive Level: Analyze (analysis) REF: 955 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 41. Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. DIF: Cognitive Level: Apply (application) REF: 960 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 42. After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions. ANS: D The patient’s history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented. DIF: Cognitive Level: Analyze (analysis) REF: 932 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 43. Which patient should the nurse assess first after receiving change-of-shift report? a. A 60-yr-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool c. A 40-yr-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute ANS: D The patient’s abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses. DIF: Cognitive Level: Analyze (analysis) REF: 938 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 44. A patient with Crohn’s disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever c. Joint pain b. Nausea d. Headache ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 970 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 45. A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas. ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible. DIF: Cognitive Level: Apply (application) REF: 959 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 46. A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient’s oral fluid intake. ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions. DIF: Cognitive Level: Analyze (analysis) REF: 933 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 47. A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough. ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient’s discomfort. DIF: Cognitive Level: Apply (application) REF: 944 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 48. A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours. ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported but are consistent with the patient’s age and diagnosis and do not require a change in the prescribed treatment. DIF: Cognitive Level: Analyze (analysis) REF: 948 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 49. A new 19-yr-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk. ANS: B Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient. DIF: Cognitive Level: Apply (application) REF: 953 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 50. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat. DIF: Cognitive Level: Analyze (analysis) REF: 964 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 51. After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems. DIF: Cognitive Level: Analyze (analysis) REF: 952 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 52. The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. “How much milk do you usually drink?” b. “Have you noticed a recent weight loss?” c. “What time of day do your bowels move?” d. “Do you eat meat or other animal products?” ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea. DIF: Cognitive Level: Analyze (analysis) REF: 968 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 53. Which information will the nurse teach a patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk. ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose. DIF: Cognitive Level: Understand (comprehension) REF: 949 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 54. Which prescribed intervention for a patient with chronic short bowel syndrome will the nurse question? a. Senna 1 tablet every day b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools ANS: A Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron- deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time. DIF: Cognitive Level: Apply (application) REF: 936 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation. ANS: B, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation. DIF: Cognitive Level: Understand (comprehension) REF: 935 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity