Ch26 Test Bank Answers Assisting With Bowel Elimination

Test Generator Questions, Chapter 26, Assisting With Bowel Elimination

Format:  Multiple Choice

Chapter Number:  26

Client Needs:  Physiological Integrity: Basic Care and Comfort

Cognitive Level:  Apply

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  598, Problems With Bowel Elimination

1. When a resident reports being “uncomfortable and gassy,” the nursing assistant offers to:

A) report to the nurse that the resident is constipated.

B) walk with the resident to the dayroom and back.

C) get the resident a glass of fruit juice.

D) insert a rectal tube.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  598, Problems With Bowel Elimination

2. The nursing assistant is caring for a mobile, older adult client who is experiencing diarrhea. What is the priority action for the nursing assistant to take?

A) Educate the client on the need to replace lost fluids with noncaffeinated drinks.

B) Use a bedside commode next to the bed so the client may use it when needed.

C) Employ adult incontinent briefs to help in the management of diarrhea.

D) Report the client’s experience of diarrhea to the nurse.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  598, Problems With Bowel Elimination

3. On inspection of a client’s stool, the nursing assistant notices that it is very black and has a tar-like appearance. The nursing assistant will:

A) place the contents of the bedpan into a specimen cup.

B) ask the nurse to come look at the contents of the bedpan.

C) dispose of the stool and then clean and disinfect the bedpan.

D) ask the resident to describe what the stool normally looks like.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  598, Problems With Bowel Elimination

4. A fecal impaction is relieved by:

A) giving an oil retention enema before removing the impaction with a gloved finger.

B) advising the person to drink plenty of water and eat more fibrous foods.

C) inserting a rectal tube that is left in place until the impaction loosens.

D) beginning a series of soapsuds enemas to lubricate the rectum.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  602, Assisting With Enemas

5. What will the nursing assistant do when a resident receiving an enema begins to report abdominal pain and cramping?

A) Loosen the clamp a bit to increase the flow rate.

B) Tighten the clamp a bit to decrease the flow rate.

C) Stop the enema and assist the resident to the bedside commode.

D) Assure the resident that pain and cramping are normal with an enema.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  602, Assisting With Enemas

6. The nursing assistant in orientation is administering a soap suds enema to a client. Which action indicates the nursing assistant requires intervention?

A) Testing the water temperature 105°F and adds castile soap to the 500 mL water.

B) Hanging the enema bag 20 inches above the anus on an intravenous pole.

C) Applying water-soluble lubricant to the tip and inserting it 3 inches into the rectum.

D) Employing the left Sims position with the upper thigh flexed toward the client’s chest.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  602, Assisting With Enemas

7. Why is it important to ensure that the temperature of the enema solution is correct?

A) Solution that is not the proper temperature can cause complications such as pain, cramping, and, possibly, death.

B) The enema solution will not cleanse the bowel properly if it is not the proper temperature.

C) The person will not be able to hold the enema solution long enough if it is not the proper temperature.

D) The person could develop diarrhea if the enema solution is not the proper temperature.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  602, Assisting With Enemas

8. The nursing assistant prepares to administer the soap suds enema and asks the resident to take a deep breath and exhale slowly before inserting the lubricated enema tip. A bleeding loop of bowel prolapses (protrudes) outside the rectum. What is the priority action for the nursing assistant to take?

A) Insert the lubricated tip 3 to 4 inches without any resistance toward the resident’s umbilicus.

B) Stop the procedure and report the observation immediately to the nurse.

C) Double-check if the clamp may be adjusted by the nursing assistant before insertion.

D) Determine whether the bedpan is nearby in case the resident needs it during the administration of the enema.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  598, Problems With Bowel Elimination

9. The nursing assistant is caring for a resident with dementia after the nurse administers the laxative suppository. After using the bedside commode, the resident has a greasy, clay-colored stool and abdominal cramping. What is the appropriate action for the nursing assistant to take?

A) Report the observations to the nurse right away.

B) Establish that this is the dissolving of the suppository.

C) Determine whether this bowel movement is usual.

D) Collect a specimen to be sent to the laboratory.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  598, Problems With Bowel Elimination

10. In an older person, the movement of food through the digestive tract may be slower. This can put the older person at risk for:

A) diabetes.

B) heart attack.

C) colon cancer.

D) constipation.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  595, Introduction to Bowel Elimination

11. Which nursing intervention is helpful to prevent an older person’s risk for constipation?

A) Keeping the client in bed most of the day

B) Increase usage of prescription pain relievers to relieve abdominal cramping

C) Hearing slowed peristalsis in the intestines

D) Drinking large amounts of liquids

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  605, Assisting With Ostomy Care

12. The nursing assistant prepares to perform the delegated task of caring for a client’s ostomy and observes that there is stool seeping around the ostomy appliance. The nursing assistant examines the supplies and is not familiar with them. What is the appropriate action for the nursing assistant to take?

A) Empty the ostomy bag into a graduate container.

B) Apply paper tape to clean skin around appliance.

C) Collect the supplies and ask the client to do it.

D) Articulate to the nurse the need for additional help.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  595, Introduction to Bowel Elimination

13. The feces would be more liquid when the colostomy is in what portion of the intestines?

A) The end of the large intestine

B) The beginning of the large intestine

C) The upper small intestine

D) The lower small intestine

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  605, Assisting With Ostomy Care

14. When providing stoma care, the skin around the stoma is cleaned with:

A) warm soapy water.

B) deodorant powder.

C) an adhesive solvent.

D) an absorbent gauze pad.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  602, Assisting With Enemas

15. The nursing assistant administers a soap suds enema to a client and, during the administration, observes that the liquid is seeping out of the anus and the client complains of discomfort. What action should the nursing assistant take?

A) Remove the enema and assist the client to the bathroom.

B) Raise the enema bag so more force may be used to deliver it.

C) Continue with administration and empty the enema bag.

D) Clamp the enema temporarily and ask the client to take deep breaths.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  605, Assisting With Ostomy Care

16. When the nursing assistant finds a client who has recently had a surgical ostomy created for intestinal cancer crying, the proper action is to:

A) give the client privacy to cry.

B) try to distract the client by talking.

C) pretend that the client isn’t crying.

D) report the client’s crying to the nurse.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  602, Obtaining a Stool Specimen

17. The nursing assistant has collected a stool sample inappropriately when:

A) touching the outside of the transport bag with a gloved hand.

B) holding the plastic transport bag with an ungloved hand.

C) placing the removed gloves in the unit’s waste container.

D) handling the specimen container with a gloved hand.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  602, Obtaining a Stool Specimen

18. Why is it necessary for the nursing assistant to collect the stool sample correctly?

A) To be sure not to come into contact with the stool

B) To decrease the risk of embarrassing the client

C) It will help the results of the test be accurate.

D) It is a facility requirement.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  605, Assisting With Ostomy Care

19. What is the primary purpose for performing stoma care?

A) Preventing skin breakdown around the stoma

B) Promoting the person’s right to have this done on a regular basis

C) Minimizing odor from the fecal matter being collected in the bag

D) Keeping the person from being embarrassed by a full collection bag

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  598, Problems With Bowel Elimination

20. The nursing assistant is caring for a client after surgery who has received pain medications for several days. The nursing assistant helps the client to use a bedpan for a bowel movement (BM) and observes liquid stool seeping from the anus. The nursing assistant cleans the client and changes the incontinence pad. What action should the nursing assistant take?

A) Apply an incontinence brief on the client.

B) Chart incontinence of stool and pericare.

C) Provide more noncaffeinated fluids to drink.

D) Articulate to the nurse that the client is impacted.