Question 1

Which actions could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

A) Assist the client to use the bedpan for bowel elimination. 
B) Change the ostomy appliance for the new ostomy. 
C) Administer a cleansing enema. 
D) Remove a fecal impaction. 
E) Determine effectiveness of cleansing enema. 
A) Assist the client to use the bedpan for bowel elimination. 
B) Change the ostomy appliance for the new ostomy. 
C) Administer a cleansing enema. 
D) Remove a fecal impaction. 
E) Determine effectiveness of cleansing enema. A,C

Question 2

The nurse assists the client off the bedpan after defecating.After emptying and cleaning the bedpan,the nurse finds the bedside table is full,and there is no room for storage of the pan.Which action by the nurse is the most appropriate?

Accepted Answer

A) Store the bedpan under the bed,where it is out of sight. 
B) Place the bedpan on the overbed table until creating a space in the bedside table. 
C) Place the bedpan on the floor of the bathroom behind or on the side of the toilet,where it is not likely to be tripped over. 
D) Remove objects from the bedside stand and return the bedpan to the stand. 
A) Store the bedpan under the bed,where it is out of sight. 
B) Place the bedpan on the overbed table until creating a space in the bedside table. 
C) Place the bedpan on the floor of the bathroom behind or on the side of the toilet,where it is not likely to be tripped over. 
D) Remove objects from the bedside stand and return the bedpan to the stand. D

Question 3

The nurse is administering a cleansing enema.Which action would indicate the need for further instruction on the process?

Accepted Answer

A) Enema solution is warmed to 40°C (105°F). 
B) The solution container is held 12 inches above the rectum. 
C) 1,000 mL of fluid is administered over 30 minutes. 
D) The client is encouraged to retain the enema for 5-10 minutes. 
A) Enema solution is warmed to 40°C (105°F). 
B) The solution container is held 12 inches above the rectum. 
C) 1,000 mL of fluid is administered over 30 minutes. 
D) The client is encouraged to retain the enema for 5-10 minutes. C

Question 4

The nurse educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances.When discussing the characteristics of ostomy appliances,which statements are appropriate for the educator to include in the presentation?

Accepted Answer

A) The ostomy appliance comes in a three-piece set. 
B) The ostomy appliance should protect the skin near the stoma. 
C) The ostomy appliance should collect both stool and urine. 
D) The ostomy appliance controls odor. 
E) All ostomy appliances can only be used once. 
A) The ostomy appliance comes in a three-piece set. 
B) The ostomy appliance should protect the skin near the stoma. 
C) The ostomy appliance should collect both stool and urine. 
D) The ostomy appliance controls odor. 
E) All ostomy appliances can only be used once.

Question 5

The nurse is caring for a client who complains of frequent constipation.Which factor in the client's history is least likely to be the cause of the constipation?

Accepted Answer

A) Inadequate fluid intake 
B) Repeated inhibition of the urge to defecate 
C) Inadequate fiber intake 
D) The presence of Escherichia coli 
A) Inadequate fluid intake 
B) Repeated inhibition of the urge to defecate 
C) Inadequate fiber intake 
D) The presence of Escherichia coli

Question 6

The nurse is working with an unlicensed assistive personnel (UAP)in a long-term care facility.Which tasks can the nurse delegate to the UAP?

Accepted Answer

A) Administering an enema to a stable client 
B) Removing a fecal impaction for an unstable client 
C) Assisting a client to perform ostomy care after hand surgery 
D) Helping a client onto a bedpan 
E) Assessing skin during an ostomy appliance change 
A) Administering an enema to a stable client 
B) Removing a fecal impaction for an unstable client 
C) Assisting a client to perform ostomy care after hand surgery 
D) Helping a client onto a bedpan 
E) Assessing skin during an ostomy appliance change

Question 7

The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago.When changing the client's one-piece appliance,the nurse finds the skin under the skin barrier is ulcerated and erythematous.The client does not empty the pouch until it is completely full because it hurts so much to remove the skin barrier.Which action by the nurse is the priority?

Accepted Answer

A) Apply a two-piece ostomy appliance. 
B) Treat the damaged skin and replace the one-piece pouch. 
C) Keep the skin open to air to allow time for healing,and replace the ostomy appliance in a few days. 
D) Call the health care provider to report the damaged skin. 
A) Apply a two-piece ostomy appliance. 
B) Treat the damaged skin and replace the one-piece pouch. 
C) Keep the skin open to air to allow time for healing,and replace the ostomy appliance in a few days. 
D) Call the health care provider to report the damaged skin.

Question 8

The nurse is changing the ostomy appliance for a client with a new loop colostomy.Which action by the nurse is the most appropriate?

Accepted Answer

A) Remove the plastic bridge in order to create a tight fit with the ostomy appliance. 
B) Cut two holes in the skin barrier for each loop. 
C) Cut an opening in the skin barrier for only the afferent or proximal end of the stoma. 
D) Place a piece of tissue or gauze over the stoma,and use a guide to measure the size of the stoma. 
A) Remove the plastic bridge in order to create a tight fit with the ostomy appliance. 
B) Cut two holes in the skin barrier for each loop. 
C) Cut an opening in the skin barrier for only the afferent or proximal end of the stoma. 
D) Place a piece of tissue or gauze over the stoma,and use a guide to measure the size of the stoma.

Question 9

The nurse is caring for a client who is on complete bed rest secondary to a deep vein thrombosis in the right leg.When placing the client on the bedpan,which position is most appropriate?

Accepted Answer

A) Prone 
B) Semi-Fowler's 
C) Fowler's 
D) Supine 
A) Prone 
B) Semi-Fowler's 
C) Fowler's 
D) Supine

Question 10

While the nurse is removing a fecal impaction,the client begins to perspire profusely and complains of shortness of breath.The nurse notes that the client's pulse rate has slowed to 44 beats per minute.Which is the priority action by the nurse?

Accepted Answer

A) Holding the fingers still until the symptoms stop,and then resuming removal of fecal impaction 
B) Stopping the procedure immediately 
C) Continuing the procedure,and monitoring the client carefully 
D) Stopping the procedure and calling the health care provider immediately 
A) Holding the fingers still until the symptoms stop,and then resuming removal of fecal impaction 
B) Stopping the procedure immediately 
C) Continuing the procedure,and monitoring the client carefully 
D) Stopping the procedure and calling the health care provider immediately

Question 11

The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal odor.Which term will the nurse use when documenting the type of colostomy for this client?

Accepted Answer

A) Ileostomy 
B) Ascending colostomy 
C) Transverse colostomy 
D) Descending colostomy 
A) Ileostomy 
B) Ascending colostomy 
C) Transverse colostomy 
D) Descending colostomy

Question 12

The nurse is caring for a toddler-age client whose mother states,"No matter what I do,I cannot get her to use the toilet for bowel movements.What would you suggest I do?" Which response by the nurse is the most appropriate?

Accepted Answer

A) "I would suggest you consult her pediatrician for further testing,because she should be able to control her bowels." 
B) "I would suggest you consult a pediatric psychologist to determine why she is resistant to potty training." 
C) "Resistance to toilet training can be very frustrating.She really isn't old enough to control her need to stool yet,and probably won't gain control until she is 18-24 months." 
D) "I bet you get tired of changing diapers.Have you tried offering her a reward when she stools in the toilet?" 
A) "I would suggest you consult her pediatrician for further testing,because she should be able to control her bowels." 
B) "I would suggest you consult a pediatric psychologist to determine why she is resistant to potty training." 
C) "Resistance to toilet training can be very frustrating.She really isn't old enough to control her need to stool yet,and probably won't gain control until she is 18-24 months." 
D) "I bet you get tired of changing diapers.Have you tried offering her a reward when she stools in the toilet?"

Question 13

The nurse is caring for a client with a newly created ostomy.After changing the ostomy appliance,which items will the nurse include when documenting the procedure?

Accepted Answer

A) How the drainage was disposed 
B) Quantity of drainage recorded on output record 
C) Any client participation in the procedure 
D) Assessment of stoma and skin around the stoma 
E) The odor of the drainage 
A) How the drainage was disposed 
B) Quantity of drainage recorded on output record 
C) Any client participation in the procedure 
D) Assessment of stoma and skin around the stoma 
E) The odor of the drainage

Question 14

The nurse is providing ostomy care for a client with a colostomy.Which assessment findings would the nurse report to the health care provider if noted during the procedure?

Accepted Answer

A) No change in stoma size 
B) A stoma that appears dry and grey in color 
C) The presence of skin irritation 
D) The amount of drainage 
E) The odor of the drainage 
A) No change in stoma size 
B) A stoma that appears dry and grey in color 
C) The presence of skin irritation 
D) The amount of drainage 
E) The odor of the drainage

Question 15

The nurse is caring for a client with abdominal distention who is unable to expel flatus.Which type of enema would the nurse anticipate administering?

Accepted Answer

A) Cleansing enema 
B) Carminative enema 
C) Retention enema 
D) Soapsuds enema 
A) Cleansing enema 
B) Carminative enema 
C) Retention enema 
D) Soapsuds enema

Exam 21: Assisting With Fecal Elimination

Which actions could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

The nurse assists the client off the bedpan after defecating.After emptying and cleaning the bedpan,the nurse finds the bedside table is full,and there is no room for storage of the pan.Which action by the nurse is the most appropriate?

The nurse is administering a cleansing enema.Which action would indicate the need for further instruction on the process?

The nurse educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances.When discussing the characteristics of ostomy appliances,which statements are appropriate for the educator to include in the presentation?

The nurse is caring for a client who complains of frequent constipation.Which factor in the client's history is least likely to be the cause of the constipation?

The nurse is working with an unlicensed assistive personnel (UAP)in a long-term care facility.Which tasks can the nurse delegate to the UAP?

The nurse is changing the ostomy appliance for a client with a new loop colostomy.Which action by the nurse is the most appropriate?

The nurse is caring for a client who is on complete bed rest secondary to a deep vein thrombosis in the right leg.When placing the client on the bedpan,which position is most appropriate?

While the nurse is removing a fecal impaction,the client begins to perspire profusely and complains of shortness of breath.The nurse notes that the client's pulse rate has slowed to 44 beats per minute.Which is the priority action by the nurse?

The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal odor.Which term will the nurse use when documenting the type of colostomy for this client?

The nurse is caring for a toddler-age client whose mother states,"No matter what I do,I cannot get her to use the toilet for bowel movements.What would you suggest I do?" Which response by the nurse is the most appropriate?

The nurse is caring for a client with a newly created ostomy.After changing the ostomy appliance,which items will the nurse include when documenting the procedure?

The nurse is providing ostomy care for a client with a colostomy.Which assessment findings would the nurse report to the health care provider if noted during the procedure?

The nurse is caring for a client with abdominal distention who is unable to expel flatus.Which type of enema would the nurse anticipate administering?

Foundational Skills

Vital Signs

Health Assessment

Diagnostic Testing

Client Hygiene

Bed-Making

Infection Control

Heat and Cold Therapy

Pain Management

Positioning the Client

Mobilizing the Client

Fall Prevention and Restraints

Maintaining Joint Mobility

Drug Calculations

Administering Oral and Enteral Medications

Administering Topical Medications

Administering Parenteral Medications

Administering Intravenous Therapy

Feeding Clients

Assisting With Urinary Elimination

Caring for Clients With Peritoneal Dialysis

Promoting Circulation

Breathing Exercises

Oxygen Therapy

Suctioning

Caring for the Client With a Tracheostomy

Assisting With Mechanical Ventilation

Caring for the Client With Chest Tube Drainage

Administering Emergency Measures to the Hospitalized Client

Performing Wound and Pressure Ulcer Care

Orthopedic Care

Performing Perioperative Care

End-Of-Life Care

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