ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 39 : Bowel Elimination Questions
Question 1 of 5
A nurse caring for a patient who reports frequent constipation learns the patient uses phosphate and sodium citrate enemas several times weekly. What education would the nurse provide?
Correct Answer: C
Rationale: Phosphate and sodium citrate enemas (
C) are contraindicated in kidney failure due to risk of hyperphosphatemia. Fiber (
A) promotes regularity, activity (
B) aids peristalsis, and fluid restriction (
D) worsens constipation.
Question 2 of 5
A nurse asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
Correct Answer: C
Rationale: The guaiac test (
C) detects occult blood in stool, screening for GI bleeding or cancer. It doesn't replace colonoscopy (
A), detect organisms (
B), or assess antibodies (
D).
Question 3 of 5
A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
Correct Answer: A
Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation (
A) follows inspection because palpation may alter bowel sounds. Percussion (
B) and palpation (C,
D) come later to avoid disturbing peristalsis.
Question 4 of 5
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
Correct Answer: C
Rationale: Severe cramping during an enema suggests the solution is too cold or the flow rate is too fast. Lowering the container and checking temperature and flow rate (
C) addresses this. Elevating the bed (
A) or changing position (
B) doesn't resolve cramping, and removing the tube (
D) is premature.
Question 5 of 5
A nurse working on a GI unit is caring for a group of patients. In patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes? Select all that apply.
Correct Answer: A,B,F
Rationale: Decreased or absent bowel sounds indicate reduced motility, common in peritonitis (
A), prolonged bedrest (
B), and paralytic ileus (F). Diarrhea (
C), gastroenteritis (
D), and early bowel obstruction (E) typically cause hyperactive bowel sounds due to increased motility.