Fundamentals Of Nursing NCLEX Quiz 15

1. Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?

Constipation

Diarrhea

Incontinence

Hemorrhoids

Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result-if anything. there is increased opportunity for water reabsorption because the stool remains in the colon. leading to firmer stool. Ignoring the urge shows a strong voluntary sphincter. not a weak one that could result in incontinence. Hemorrhoids would only occur only if severe drying out of the stool occurs. and thus repeated need to strain to pass stool.

Explanation

Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result-if anything. there is increased opportunity for water reabsorption because the stool remains in the colon. leading to firmer stool. Ignoring the urge shows a strong voluntary sphincter. not a weak one that could result in incontinence. Hemorrhoids would only occur only if severe drying out of the stool occurs. and thus repeated need to strain to pass stool.

2. A nurse determines that a fracture bedpan should be used for the patient who:

Has a spinal cord injury.

Is on bedrest.

Has dementia.

Is obese

A fracture bedpan has a low back that promotes function of the patient’s lower back while on the bedpan.

Explanation

A fracture bedpan has a low back that promotes function of the patient’s lower back while on the bedpan.

3. Which of the following is most likely to validate that a client is experiencing intestinal bleeding?

Large quantities of fat mixed with pale yellow liquid stool.

Brown. formed stool.

Semi soft tar colored stools.

Narrow. Pencil shaped stool

Blood in the upper G.I. tract is black and tarry. Option one can be a sign of malabsorption in an infant. option two is normal stool. and option four is characteristic of an obstructive condition of the rectum.

Explanation

Blood in the upper G.I. tract is black and tarry. Option one can be a sign of malabsorption in an infant. option two is normal stool. and option four is characteristic of an obstructive condition of the rectum.

4. Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?

“I need to drink one and a half to 2 quarts of liquid each day.”

“I need to take a laxative such as milk of magnesia or if I don’t have a BM every day.”

“If my bowel pattern changes on its own. I should call you.”

“Eating my meals at regular times is likely to result in regular bowel movements.”

The standard of practice in assisting the older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet. adequate fluid intake. and regular exercise. If the bowel pattern is not regular with these activities. this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition. a normal stool pattern for an older adult may not be daily elimination.

Explanation

The standard of practice in assisting the older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet. adequate fluid intake. and regular exercise. If the bowel pattern is not regular with these activities. this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition. a normal stool pattern for an older adult may not be daily elimination.

5. The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

The stoma extends 1/2 inch above the abdomen.

The skin under the appliance looks red briefly after removing the appliance.

The stoma color is a deep red purple.

An ascending colostomy just delivers liquid feces

An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off feces from an ascending ostomy are very liquid. less so from a transverse ostomy. and more solid from a descending or sigmoid stoma.

Explanation

An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off feces from an ascending ostomy are very liquid. less so from a transverse ostomy. and more solid from a descending or sigmoid stoma.

6. The nurse assesses a client's abdomen several days after abdominal surgery. It is firm. distended. and painful to palpate. The client reports feeling "bloated" the nurse consult with the surgeon. who orders an enema. The nurse prepares to give what kind of enema?

Soapsuds

Retention

Return flow

Oil retention

This provides relief of postoperative flatus. stimulating bowel motility. Options one. two. and four manage constipation and do not provide flatus relief.

Explanation

This provides relief of postoperative flatus. stimulating bowel motility. Options one. two. and four manage constipation and do not provide flatus relief.

7. Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?

The client will wear a medical alert bracelet for antibiotic allergy.

The client will return to his or her previous fecal elimination pattern.

The client verbalizes the need to take an antidiarrheal medication PRN.

The client will increase intake of insoluble fiber such as grains. rice. and cereals.

Once the cause of diarrhea has been identified and corrected. the client to return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug. Antidiarrheal medications are usually prescribed according to the number of stools. not routinely around the clock. Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea. but insoluble fiber will not.

Explanation

Once the cause of diarrhea has been identified and corrected. the client to return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug. Antidiarrheal medications are usually prescribed according to the number of stools. not routinely around the clock. Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea. but insoluble fiber will not.

8. A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

Prepare to irrigate the colostomy.

After assessing the stoma and surrounding skin. notify the surgeon.

Assess bowel sounds and administer antiemetic.

Administer a bulk forming laxative. and encourage increased fluids and exercise.

The client has assessment findings consistent with complications of surgery. Option A: irrigating the stoma is a dependent nursing action. and is also intervention without appropriate assessment. Option C: assessing the peristomal skin area is an independent action. but administering an antiemetic is an intervention without appropriate assessment. antiemetics are generally ordered to treat immediate postoperative nausea. not several days postoperative. Option D: administering a bulk forming laxative to a nauseated postoperative client is contraindicated

Explanation

The client has assessment findings consistent with complications of surgery. Option A: irrigating the stoma is a dependent nursing action. and is also intervention without appropriate assessment. Option C: assessing the peristomal skin area is an independent action. but administering an antiemetic is an intervention without appropriate assessment. antiemetics are generally ordered to treat immediate postoperative nausea. not several days postoperative. Option D: administering a bulk forming laxative to a nauseated postoperative client is contraindicated

9. A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?

Oil retention

Return flow

High large volume

Low. small volume

Small volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool. Return flow enemas help expel flatus because of the risk of loss of fluid and electrolytes high.large volume enemas are seldom used.

Explanation

Small volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool. Return flow enemas help expel flatus because of the risk of loss of fluid and electrolytes high.large volume enemas are seldom used.

10. Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply.

Bowel incontinence

Risk for deficient fluid volume

Disturbed body image

Social isolation

Risk for impaired skin integrity

Option A is the most appropriate. The client is unable to decide when stool evacuation will occur. In option C. client thoughts about self may be altered if unable to control stool evacuation. In option E. increased tissue contact with fecal material may result in impairment. Option B is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

Explanation

Option A is the most appropriate. The client is unable to decide when stool evacuation will occur. In option C. client thoughts about self may be altered if unable to control stool evacuation. In option E. increased tissue contact with fecal material may result in impairment. Option B is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

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