Question 1

A right-handed nurse needs to remove the patient's nasogastric (NG)tube.Which intervention maintains patient safety during removal of the NG tube?

Accepted Answer

A)  Leaving the suction on the low setting 
B)  Clamping and then pulling out the tube 
C)  Standing on the patient's left side 
D)  Asking the patient to inhale deeply 
A)  Leaving the suction on the low setting 
B)  Clamping and then pulling out the tube 
C)  Standing on the patient's left side 
D)  Asking the patient to inhale deeply B

Question 2

A patient's nasogastric tube needs to be irrigated.Which action does the nurse implement first to prevent complications?

Accepted Answer

A)  Introduces 30 mL of sterile fluid 
B)  Verifies the placement of the tube 
C)  Aspirates gastric contents 
D)  Positions the patient on the left side 
A)  Introduces 30 mL of sterile fluid 
B)  Verifies the placement of the tube 
C)  Aspirates gastric contents 
D)  Positions the patient on the left side B

Question 3

1. A ________ ________ device is a useful intervention for patients with severe fecal incontinence,such as those with Clostridium difficile-associated diarrhea.

Accepted Answer

fecal containment
Fecal containment devices are an effective way to prevent skin damage due to moisture and enzyme action on perianal tissues.

Question 4

The nurse is providing routine care for a patient with a nasogastric (NG)tube.Care by the nurse is correct if which technique is used?

Accepted Answer

A)  Alternates NG tube placement between the nares daily 
B)  Provides patient oral care daily and lubricant to the lips 
C)  Keeps the head of the bed flat with the tube in place 
D)  Prevents pressure on the nasal tissue 
A)  Alternates NG tube placement between the nares daily 
B)  Provides patient oral care daily and lubricant to the lips 
C)  Keeps the head of the bed flat with the tube in place 
D)  Prevents pressure on the nasal tissue

Question 5

The nurse is preparing to insert a nasogastric (NG)tube.Which techniques should the nurse use to measure the length of an NG tube before gastric intubation?

Accepted Answer

A)  Measure and mark a point 72 cm (30 inches) from the end. 
B)  Measure from the nose to the middle of the sternum. 
C)  Measure from the nose to the ear to the patient's navel. 
D)  Measure from the nose to the earlobe to the xiphoid process. 
A)  Measure and mark a point 72 cm (30 inches) from the end. 
B)  Measure from the nose to the middle of the sternum. 
C)  Measure from the nose to the ear to the patient's navel. 
D)  Measure from the nose to the earlobe to the xiphoid process.

Question 6

The nurse is inserting a nasogastric (NG)tube and assessing the patient during the procedure.Which assessment finding indicates a potentially serious problem?

Accepted Answer

A)  Restlessness 
B)  Inability to speak 
C)  Nasal pressure 
D)  Mouth breathing 
A)  Restlessness 
B)  Inability to speak 
C)  Nasal pressure 
D)  Mouth breathing

Question 7

A patient requires digital removal of a fecal impaction.Which action should the nurse perform before beginning this procedure?

Accepted Answer

A)  Administer large-volume tap water enemas until clear. 
B)  Assist the patient into the dorsal recumbent position. 
C)  Check for an order from the healthcare provider. 
D)  Delegate the procedure to nursing assistive personnel (NAP). 
A)  Administer large-volume tap water enemas until clear. 
B)  Assist the patient into the dorsal recumbent position. 
C)  Check for an order from the healthcare provider. 
D)  Delegate the procedure to nursing assistive personnel (NAP).

Question 8

The patient's nasogastric (NG)tube drains approximately 400 mL/day of yellow-green drainage.When the patient begins to complain of nausea,which intervention should the nurse implement first?

Accepted Answer

A)  Irrigate the tube with 50 mL of water. 
B)  Assess the patency of the NG tube. 
C)  Replace the NG tube with a much larger tube. 
D)  Elevate the patient's head and reassess. 
A)  Irrigate the tube with 50 mL of water. 
B)  Assess the patency of the NG tube. 
C)  Replace the NG tube with a much larger tube. 
D)  Elevate the patient's head and reassess.

Question 9

A patient is weak,has diarrhea,and is refusing to use the bedpan but is on bed rest and unable to get out of bed.Which is the best nursing intervention to maintain patient dignity?

Accepted Answer

A)  Keep the bedpan out of the patient's sight until it is needed. 
B)  Reassure the patient that most people use the bedpan willingly. 
C)  Instruct the patient that the only alternative for elimination is to use the bedpan. 
D)  Explain to the patient how the nurse ensures privacy and safety when the patient is using the bedpan. 
A)  Keep the bedpan out of the patient's sight until it is needed. 
B)  Reassure the patient that most people use the bedpan willingly. 
C)  Instruct the patient that the only alternative for elimination is to use the bedpan. 
D)  Explain to the patient how the nurse ensures privacy and safety when the patient is using the bedpan.

Question 10

A home care patient has a history of fecal impaction.Which intervention does the nurse instruct the home health aide to implement to prevent another fecal impaction?

Accepted Answer

A)  Provide the patient with low-residue foods. 
B)  Notify the provider of patient abdominal pain. 
C)  Administer a cleansing enema every 3 days. 
D)  Encourage and assist the patient to take additional fluids daily. 
A)  Provide the patient with low-residue foods. 
B)  Notify the provider of patient abdominal pain. 
C)  Administer a cleansing enema every 3 days. 
D)  Encourage and assist the patient to take additional fluids daily.

Question 11

The nurse records a patient's intake and output for an 8-hour period and notes nasogastric (NG)tube irrigation with 50 mL of normal saline solution every 4 hours and lactulose syrup,30 mL,instilled through the NG tube with 30 mL of normal saline solution.Which total should the nurse record as the patient's intake over 8 hours?

Accepted Answer

A)  30 mL 
B)  160 mL 
C)  110 mL 
D)  210 mL 
A)  30 mL 
B)  160 mL 
C)  110 mL 
D)  210 mL

Question 12

2. When considering the application of a fecal containment device,it is important to assess the patient for ______ allergies.

Accepted Answer

latex
Assess patient

Question 13

A patient in skeletal traction for a fractured pelvis needs to use the bedpan.Which intervention should the nurse use to prevent complications?

Accepted Answer

A)  Logroll the patient and maintain skeletal traction. 
B)  Place a bedpan under the patient while the hips are lifted. 
C)  Remove weights on the traction and turn the patient. 
D)  Warm the bedpan before placing it under the patient. 
A)  Logroll the patient and maintain skeletal traction. 
B)  Place a bedpan under the patient while the hips are lifted. 
C)  Remove weights on the traction and turn the patient. 
D)  Warm the bedpan before placing it under the patient.

Question 14

During insertion of a nasogastric (NG)tube,the patient begins to cough and gag.Which intervention should the nurse implement for the patient's benefit?

Accepted Answer

A)  Withdraw the tube slightly and ask the patient to swallow. 
B)  Stop the procedure, anchor the tube, and request an x-ray film. 
C)  Tell the patient that the gagging will pass, and advance the tube. 
D)  Remove the tube and allow the patient to regain composure. 
A)  Withdraw the tube slightly and ask the patient to swallow. 
B)  Stop the procedure, anchor the tube, and request an x-ray film. 
C)  Tell the patient that the gagging will pass, and advance the tube. 
D)  Remove the tube and allow the patient to regain composure.

Question 15

The patient is alert and cooperative for insertion of a nasogastric (NG)tube.In which position should the nurse place the patient for the procedure?

Accepted Answer

A)  Sitting upright but leaning back slightly 
B)  In left lateral Sims' position with the head elevated 
C)  Leaning forward on the overbed table 
D)  Any position that is comfortable 
A)  Sitting upright but leaning back slightly 
B)  In left lateral Sims' position with the head elevated 
C)  Leaning forward on the overbed table 
D)  Any position that is comfortable

Question 16

The nurse performs digital removal of a fecal impaction for a patient with atrial fibrillation and heart failure.Which is the most serious unexpected outcome that the nurse assesses during the procedure?

Accepted Answer

A)  Rectal bleeding 
B)  Perianal redness 
C)  Liquid stool leakage after removal of the impaction 
D)  Abdominal cramping 
A)  Rectal bleeding 
B)  Perianal redness 
C)  Liquid stool leakage after removal of the impaction 
D)  Abdominal cramping

Question 17

The nurse implements the teaching plan for a patient with chronic constipation.Which of the following outcomes indicates patient teaching has been effective?

Accepted Answer

A)  The patient passes a small liquid stool daily. 
B)  The patient has a firm stool every fourth day. 
C)  The patient reports less frequent abdominal cramping. 
D)  The patient describes methods to prevent constipation. 
A)  The patient passes a small liquid stool daily. 
B)  The patient has a firm stool every fourth day. 
C)  The patient reports less frequent abdominal cramping. 
D)  The patient describes methods to prevent constipation.

Question 18

The nurse performs digital removal of feces for a patient.Which patient diagnosis cues the nurse to assess the patient more frequently than usual during the procedure?

Accepted Answer

A)  Abdominal pain 
B)  Atrial fibrillation 
C)  Urinary infection 
D)  Diabetes mellitus 
A)  Abdominal pain 
B)  Atrial fibrillation 
C)  Urinary infection 
D)  Diabetes mellitus

Question 19

The nurse assesses a patient during digital removal of a fecal impaction.Which patient assessment finding does the nurse determine to be unexpected?

Accepted Answer

A)  Complaints of abdominal cramping 
B)  Large amount of brown, liquid stool 
C)  Blood pressure 130/86 mm Hg, stable 
D)  Heart monitor showing sinus bradycardia 
A)  Complaints of abdominal cramping 
B)  Large amount of brown, liquid stool 
C)  Blood pressure 130/86 mm Hg, stable 
D)  Heart monitor showing sinus bradycardia

Question 20

During preparation for removal of a nasogastric (NG)tube,the patient becomes anxious.Which action should the nurse take to reassure the patient before removing the NG tube?

Accepted Answer

A)  Grasp the tube and remove it quickly. 
B)  Medicate the patient with an analgesic. 
C)  Tell the patient this procedure is painless. 
D)  Inform the patient that it only takes a few seconds. 
A)  Grasp the tube and remove it quickly. 
B)  Medicate the patient with an analgesic. 
C)  Tell the patient this procedure is painless. 
D)  Inform the patient that it only takes a few seconds.

Exam 19: Bowel Elimination and Gastric Intubation

A right-handed nurse needs to remove the patient's nasogastric (NG)tube.Which intervention maintains patient safety during removal of the NG tube?

A patient's nasogastric tube needs to be irrigated.Which action does the nurse implement first to prevent complications?

1. A ________ ________ device is a useful intervention for patients with severe fecal incontinence,such as those with Clostridium difficile-associated diarrhea.

The nurse is providing routine care for a patient with a nasogastric (NG)tube.Care by the nurse is correct if which technique is used?

The nurse is preparing to insert a nasogastric (NG)tube.Which techniques should the nurse use to measure the length of an NG tube before gastric intubation?

The nurse is inserting a nasogastric (NG)tube and assessing the patient during the procedure.Which assessment finding indicates a potentially serious problem?

A patient requires digital removal of a fecal impaction.Which action should the nurse perform before beginning this procedure?

The patient's nasogastric (NG)tube drains approximately 400 mL/day of yellow-green drainage.When the patient begins to complain of nausea,which intervention should the nurse implement first?

A patient is weak,has diarrhea,and is refusing to use the bedpan but is on bed rest and unable to get out of bed.Which is the best nursing intervention to maintain patient dignity?

A home care patient has a history of fecal impaction.Which intervention does the nurse instruct the home health aide to implement to prevent another fecal impaction?

2. When considering the application of a fecal containment device,it is important to assess the patient for ______ allergies.

A patient in skeletal traction for a fractured pelvis needs to use the bedpan.Which intervention should the nurse use to prevent complications?

During insertion of a nasogastric (NG)tube,the patient begins to cough and gag.Which intervention should the nurse implement for the patient's benefit?

The patient is alert and cooperative for insertion of a nasogastric (NG)tube.In which position should the nurse place the patient for the procedure?

The nurse performs digital removal of a fecal impaction for a patient with atrial fibrillation and heart failure.Which is the most serious unexpected outcome that the nurse assesses during the procedure?

The nurse implements the teaching plan for a patient with chronic constipation.Which of the following outcomes indicates patient teaching has been effective?

The nurse performs digital removal of feces for a patient.Which patient diagnosis cues the nurse to assess the patient more frequently than usual during the procedure?

The nurse assesses a patient during digital removal of a fecal impaction.Which patient assessment finding does the nurse determine to be unexpected?

During preparation for removal of a nasogastric (NG)tube,the patient becomes anxious.Which action should the nurse take to reassure the patient before removing the NG tube?

Using Evidence in Nursing Practice

Communication and Collaboration

Documentation and Informatics

Patient Safety and Quality Improvement

Infection Control

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Bathing and Personal Hygiene

Care of the Eye and Ear

Promoting Nutrition

Pain Management

Promoting Oxygenation

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Traction, cast Care, and Immobilization Devices

Urinary Elimination

Ostomy Care

Preparation for Safe Medication Administration

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Wound Care and Irrigation

Pressure Ulcers

Dressings,bandages,and Binders

Intravenous and Vascular Access Therapy

Preoperative and Postoperative Care

Emergency Measures for Life Support in the Hospital Setting

Palliative Care

Home Care Safety

Filters

1. A device is a useful intervention for patients with severe fecal incontinence,such as those with Clostridium difficile-associated diarrhea.