Question 1

The nurse is caring for a patient who has diarrhea.Which nursing action is the highest priority?

Accepted Answer

A)   Provide perineal skin care.
B)   Auscultate the abdomen daily.
C)   Encourage oral fluid replacement.
D)   Provide analgesics for abdominal pain. C

Question 2

The nurse is contributing to a patient's plan of care.Which foods should the nurse recommend to be avoided or used with caution to reduce the possibility of ileostomy blockage? (Select all that apply.)

Accepted Answer

A)   Celery
B)   Apples
C)   Potatoes
D)   Dried fruits
E)   MushroomsF)  Broiled chicken A,B,D,E

Question 3

On admission,a patient with gastrointestinal bleeding had vital signs of a blood pressure of 140/80 mm Hg,pulse 72 beats/minute,respirations 14 breaths/minute,and temperature 98.8°F (37.1°C).What finding should be reported to the registered nurse (RN)or physician immediately?

Accepted Answer

A)   Pulse 78 beats/minute
B)   Crampy abdominal pain
C)   Occult blood in the stool
D)   Blood pressure 104/68 mm Hg D

Question 4

The nurse is reinforcing teaching provided to a patient about appropriate diet modifications to help prevent exacerbations of inflammatory bowel disease.Which patient statements indicate that teaching has been effective? (Select all that apply.)

Accepted Answer

A)   "I should avoid caffeine and spicy fiber foods."
B)   "I should avoid concentrated sweets and starches."
C)   "It is important to eat more whole grains and bran."
D)   "High-fiber foods should not be included in my diet."
E)   "I should increase my intake of fresh fruits and vegetables."F)  "Milk and other dairy products should be limited in my diet."

Question 5

The nurse is caring for a patient with an inflamed appendix.Which complication is most likely to occur if the appendix ruptures?

Accepted Answer

A)   Colitis
B)   Enteritis
C)   Hepatitis
D)   Peritonitis

Question 6

The nurse is collecting data from a patient with a stoma.What should the nurse document for a health stoma?

Accepted Answer

A)   Gray and dry
B)   Black and dry
C)   Bluish and wet
D)   Pink and moist

Question 7

A patient with fecal incontinence has an excoriated perianal region.Which interventions should be discussed with the RN? (Select all that apply.)

Accepted Answer

A)   Stool culture
B)   Antibiotic therapy
C)   Protective barrier cream
D)   Baby powder to peri area
E)   A low-pressure rectal tubeF)  Nasogastric (NG)  tube to suction

Question 8

The nurse reinforces teaching provided to a patient with constipation and straining who is experiencing abdominal distention and intestinal rumbling.What should be included in the teaching? (Select all that apply.)

Accepted Answer

A)   Set a time for defecation every day.
B)   Increase the intake of foods containing vitamin K.
C)   Increase intake of fiber, especially bran, in the diet.
D)   Sit on the toilet with feet planted firmly on the floor.
E)   Drink water each morning and about 2 to 3 L throughout the day.F)  Use enemas and rectal suppositories if constipation persists after 2 days.

Question 9

A patient asks what causes diverticulitis.How should the nurse respond?

Accepted Answer

A)   "The lining of your colon is irritated and inflamed."
B)   "You have little pouches in your colon that are inflamed."
C)   "You have little outpouchings that occur in weak areas of the colon."
D)   "The visceral and parietal membranes in your abdomen are inflamed."

Question 10

A patient with a bowel obstruction asks for the term that describes telescoping of the bowel.Which should the nurse respond to this patient?

Accepted Answer

A)   "Ileus."
B)   "Volvulus."
C)   "Adhesions."
D)   "Intussusception."

Question 11

A patient scheduled for an ileostomy for Crohn's disease asks the nurse to explain the procedure.What should the nurse respond?

Accepted Answer

A)   "You will have a loop of colon brought out onto your abdomen."
B)   "Your ileum will be anastomosed to your rectum, so your stools will be watery."
C)   "Your ileum will be removed, and the end of your jejunum will be made into a stoma."
D)   "Your colon will be removed, and the end of your small bowel will be brought out onto your abdomen."

Question 12

The nurse is providing discharge teaching to a patient with diarrhea.Which patient statement indicates that teaching has been effective?

Accepted Answer

A)   "It is important that I increase fluid intake to prevent dehydration."
B)   "I am at increased risk for a ruptured bowel, so I must remain on bedrest."
C)   "I should tell future health-care workers that I've been diagnosed with obstipation."
D)   "My risk for a urinary tract infection is very high, so I should call the doctor if I have a pain."

Question 13

The nurse is reviewing the process of digestion with a patient diagnosed with malabsorption syndrome.How many mL of fluid should the nurse instruct that is absorbed through the intestinal mucosa into the portal bloodstream?

Accepted Answer

A)   1000
B)   2000
C)   4000
D)   8000

Question 14

A patient is experiencing melena.What does this observation indicate to the nurse?

Accepted Answer

A)   The patient has a ruptured diverticulum
B)   The patient has ingested a large volume of red meat
C)   Blood has begun to seep into the stomach over the last 3 hours from esophageal varices
D)   Blood has been in the gastrointestinal tract for more than 8 hours after being in contact with hydrochloric acid

Question 15

The nurse is reinforcing teaching provided to a patient with acute diarrhea.Which statement indicates the patient understands the most common cause for this health problem?

Accepted Answer

A)   "Excessive fluid intake."
B)   "Excessive fiber in the diet."
C)   "Viral or bacterial infection."
D)   "Inflammatory bowel disease."

Question 16

A patient comes into the client after experiencing diarrhea with five liquid stools in the past 24 hours.Which additional patient symptoms should cause the nurse concern? (Select all that apply.)

Accepted Answer

A)   Fever
B)   Blood in the stool
C)   Severe abdominal cramping
D)   Blood pressure 138/72 mm Hg
E)   Oral intake of 3 L of fluid in 24 hoursF)  Weight loss of 1 pound in the past week

Question 17

The nurse is participating in a community health fair program focusing on risk factors for cancer.Which should be included as increasing the risk for colon cancer? (Select all that apply.)

Accepted Answer

A)   Low-fat diet
B)   Low-fiber diet
C)   Low-sodium diet
D)   History of rectal polyps
E)   History of ulcerative colitisF)  Family history of breast cancer

Question 18

The nurse is caring for a patient with an exacerbation of Crohn's disease.Which nursing action is most important to recommend for inclusion in the patient's plan of care?

Accepted Answer

A)   Encourage oral fluids.
B)   Encourage frequent ambulation.
C)   Administer anti-gas agents as ordered.
D)   Apply protective ointment to perianal skin.

Question 19

The nurse is reinforcing teaching provided to a patient who is being discharged with a new colostomy.Which comments by the patient indicate understanding of the discharge teaching? (Select all that apply.)

Accepted Answer

A)   "I will empty the pouch when it is less than half full."
B)   "I can spray deodorant into the pouch after I clean it."
C)   "I will not be concerned if there is no stool for several days."
D)   "I'm so glad I can eat all the foods I like now, including hot dogs."
E)   "I always check the seal and tape around the stoma after I shower."F)  "I should change the pouch each morning and evening to prevent infection."

Question 20

The nurse is caring for a patient recovering from ileostomy surgery.What should have the highest priority when caring for the patient after surgery?

Accepted Answer

A)   Food intake
B)   Participation in stoma care
C)   Stoma condition every 8 hours
D)   Bowel sounds every 4 hours for 24 hours

Exam 34: Nursing Care of Patients With Lower Gastrointestinal Disorders