ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 39 Questions
Question 1 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 2 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 3 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 4 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 5 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.