Potter: Fundamentals of Nursing, 9th Edition
Answer Key for Bowel-Ostomy Module Post Tests and Exam
(Since questions may be reordered with each usage, the question number in the answer key may
not correspond to the nu
...
Potter: Fundamentals of Nursing, 9th Edition
Answer Key for Bowel-Ostomy Module Post Tests and Exam
(Since questions may be reordered with each usage, the question number in the answer key may
not correspond to the number that the student reports for a particular quiz item).
Lesson 1 Post Test
1. Match the gastrointestinal (GI) structure to its primary function.
Correct match:
Absorbs, protects, secretes,
eliminates
Colon
Temporarily stores feces until
elimination
Rectum
Receives enzymes from the
gallbladder and pancreas to
further break down chyme;
absorbs nutrients
Small intestine
Where peristalsis moves food to
stomach
Esophagus
Secretes hydrochloric acid and
pepsin; converts bolus of food to
chime
Stomach
Rationale: The esophagus moves food to the stomach by peristaltic action. The stomach secretes
hydrochloric acid and pepsin and converts the food bolus to chyme. The small intestine receives
enzymes from the gallbladder and pancreas to further break down chyme. Most absorption of
nutrients occurs in the small intestine. The primary functions of the colon (i.e., large intestine)
are absorption, protection, secretion, and elimination. The rectum temporarily stores feces until
elimination.
2. If a patient had to have part of their colon (large intestine) removed, which of the following
may result?
a) The patient could experience an acid-base imbalance.
b) The patient could experience increased amounts of mucus in the stool.
c) The patient could experience fluid volume overload with increased absorption.
d) Once healed, it would be unlikely for the patient to experience any alteration in
elimination.
Correct answer: a
Rationale: A primary function of the colon is the secretion of bicarbonate for chloride and the
release of potassium. Any alteration in the secretory function could result in an acid-base
imbalance. A primary function of the colon is the protection of the sensitive tissue lining of the
colon through the release of mucus. If a portion of the colon is removed, there would be fewer
mucus-secreting cells available. The colon also absorbs water, sodium, and chloride. If less water
is absorbed, the patient would be at an increased risk for diarrhea and an electrolyte imbalance.
3. A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk
for constipation if the following are present in the patient’s health history or admission
assessment? (Select all that apply.)
a) The patient is 81 years old.
b) The patient reports rare laxative use.
c) The patient takes narcotics for chronic back pain.
d) The patient eats whole grains; raw fruits; and green, leafy vegetables.
e) The patient takes daily iron and calcium supplements.
f) The patient reports daily exercise and remains active.
Correct answer: a, c, e
Rationale: As a person ages, peristalsis slows and increases the risk for constipation. Opiods,
iron supplements, and calcium supplements slow colonic action. Laxative misuse is a common
cause for constipation. A diet high in animal fats and low in fiber and fluid increases the risk for
constipation. Lengthy bed rest or lack of regular exercise are considered risk factors for
constipation.
4. The student nurse is studying the order of the GI tract in preparation for an anatomy
examination. Which of the following indicates correct understanding?
a) mouth, esophagus, stomach, colon, small intestine, anus
b) ascending colon, transverse colon, descending colon, sigmoid colon
c) stomach, duodenum, ileum, jejunum, cecum, large intestine, rectum
d) cecum, small intestine, descending colon, transverse colon, ascending colon
Correct answer: b
Rationale: The order of the colon is: ascending colon, transverse colon, descending colon,
sigmoid colon (then rectum and anus). The cecum is between the small and large intestine. The
small intestine (duodenum, jejunum, and ileum) comes before the colon (large intestine).
5. An increase in venous pressure caused by liver disease can result in the development of:
a) Hemorrhoids
b) Flatulence
c) Impaction
d) Diarrhea
Correct answer: a
Rationale: Pressure leading to hemorrhoids can also occur from straining during defecation and
from pregnancy.
6. The comatose patient in an intensive care unit (ICU), who has not had a bowel movement in 4
days, suddenly is incontinent of diarrheal stool. What should the nurse suspect?
a) Diarrhea as a result of decreased muscle tone
b) Impaction
c) A vagal response
d) Flatulence
Correct answer: b
Rationale: Prolonged constipation followed by diarrhea that seeps around the impacted stool are
symptoms of a fecal impaction.
7. The nurse is monitoring the patient for a possible vagal response while removing a fecal
impaction. If the patient would have a vagal response, what would the nurse most likely observe?
a) Tachycardia
b) Hypertension
c) A decrease in heart rate
d) A decrease in respirations
Correct answer: c
Rationale: The nurse should monitor the patient for a decrease in heart rate.
Lesson 2 Post Test
1. A patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan, he
must receive a cleansing, tap water enema. The nurse should prepare:
a) At least 2000 mL of tap water
b) 1000 mL or less of tap water
c) 5 mL of castile soap and 1500 mL of water
d) 180 mL of prepackaged (Fleets) enema solution
Correct answer: b
Rationale: A tap water enema usually contains 750 to 1000 mL for the adult. If castile soap were
to be added, the order would be for a soap suds enema. A Fleets enema is a hypertonic enema,
and that would be noted on the order. Since the order is for a clean water enema, the Fleets
product would not be appropriate.
2. The physician has ordered a Fleets enema for a patient experiencing constipation. Which of
the following actions would require correction?
a) The nurse delegates the task to an NAP.
b) The nurse removes the protective cap from the rectal tip.
c) The nurse squeezes and releases the bottle several times until all of the solution has
entered the patient.
d) The nurse administers the enema at room temperature or, if too cool, warms the
solu
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