Practice Questions
1. The nurse suspects an elderly client has become impacted when the client says:
A. "I have a lot of gas pains"
B. "I don't have much of an appetite"
C. "I felt like I have to go and just can'
...
Practice Questions
1. The nurse suspects an elderly client has become impacted when the client says:
A. "I have a lot of gas pains"
B. "I don't have much of an appetite"
C. "I felt like I have to go and just can't"
D. "I haven't had a bowel movement for 2 days"
Rationale: Because of the presence of feces in the colon, a client with a fecal impaction has
the urge to defecate but is unable to. Flatulence may occur as a result of immobility not
just obstruction. Anorexia may occur with a fecal impaction but may also be caused by
other conditions. The frequency of bowel movements varies for individuals; it may be
normal for this individual not to have a bowel movement for several days .
2. A client with hepatic cirrhosis begins to develop slurred speech, confusion,
drowsiness, and a flapping tremor. With this evidence of impending hepatic coma,
the diet would probably be changed to:
A. 20 g protein, 2000 calories
B. 70 g protein, 1200 calories
C. 80 g protein, 2500 calories
D. 100 g protein, 1500 calories
Rationale: Because the liver is unable to detoxify ammonia to urea, and when hepatic
coma is inevitable, protein intake should be restricted (20 g protein and 2000 calories). The
other options have relatively high intake of protein, which will increase blood ammonia
levels .
3. After a partial gastrectomy is performed, a client is returned to the unit with an
IV solution infusing and a nasogastric tube in place. The nurse notes that there has
been no drainage from the nasogastric tube for an hour. There is an order to
irrigate the NG tube PRN. The nurse should:
A. Instill 30 ml of normal saline and withdraw slowly
B. Instill 20 ml of air and clamp off suction for 1 hour
C. Instill 50 ml of saline and increase pressure of suction
D. Instill 15 ml of distilled water and disconnect suction for 30 minutes
Rationale: Normal saline is used in irrigation to prevent electrolyte imbalance. Because of
the fresh gastric sutures, slow and gentle irrigation should be performed. The purpose of
irrigation is to maintain the patency of the tube for gastric decompression. Pushing air
and clamping the suction tube can result in blocking the NG tube by viscous drainage.
Increasing the pressure or disconnecting suction may cause damage to the suture line .
4. When performing a colostomy irrigation, the nurse inserts the catheter into the
stoma up to:
A. 5 cm (2 inches)
B. 10 cm (4 inches)
C. 15 cm (6 inches)
D. 20 cm (8 inches)
Rationale: 10 cm is far enough to direct the flow of solution into the bowel. Insertion of 5
cm is inadequate—fluid may leak back around the catheter. An insertion of 15 cm may
cause trauma to the mucosa .
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