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 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 2 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.
Question 3 of 5
A nurse in a long-term care facility is assessing a group of patients. In which patients would the nurse anticipate increased risk for developing diarrhea? Select all that apply.
Correct Answer: B,E,F
Rationale: Diarrhea is a side effect of metformin (
B), amoxicillin clavulanate (E), and magnesium-containing antacids (F). Opioids (
A), diuretics (
C), and dehydration (
D) are more likely to cause constipation.
Question 4 of 5
A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
Correct Answer: C
Rationale: Retention enemas require the patient to hold the solution for at least 30 minutes (
C) to soften stool. Large volumes (
A) are for cleansing enemas, milk and molasses (
B) are for carminative enemas, and administering on the toilet (
D) prevents retention.
Question 5 of 5
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.
Correct Answer: D,E,F
Rationale: Ileostomy stool is liquid (
D), dark-green vegetables reduce odor (E), and food blockages are a risk (F). The stoma should be pink/red, not purple-blue (
A), stabilizes in 4-6 weeks, not 2 (
B), and skin should be clean and dry, not moist (
C).