Deck 35: Bowel Elimination and Gastric Intubation

Question 1

When providing care for a patient who is disoriented during a nasogastric (NG)tube placement,which intervention is important for the nurse to implement?

A) Halt the procedure.
B) Request assistance with insertion.
C) Administer a hypnotic medication.
D) Continue the procedure as with any other patient.

Answer 1

Request assistance with insertion.

Question 2

In advancing the nasogastric (NG)tube,which technique provides the safest outcome?

A) Rotate the tube if resistance is felt.
B) Advance the tube in between swallows.
C) Start with the patient's head flexed.
D) Check the tube placement by instilling air and auscultating over the stomach.

Answer 2

Rotate the tube if resistance is felt.

Question 3

When preparing an infant for an enema,the nurse understands that which solution is the safest?

A) Tap-water enema solution
B) Hypertonic enema solution
C) Oil retention
D) Physiological normal saline

Answer 3

Physiological normal saline

Question 4

When care is provided for a patient with a nasogastric (NG)tube in place,which intervention is safest for the nurse to implement?

A) Tape the tube up and around the ear on the side of insertion.
B) Secure the tubing to the bed by the patient's head.
C) Mark the tube where it exits the nose.
D) Change the tubing daily.

Question 5

While the nurse is administering an enema,the patient complains of some cramping.Which action should the nurse take next?

A) Discontinue the procedure completely.
B) Increase the height of the solution.
C) Slow the rate of infusion.
D) Have the patient roll into a supine position.

Question 6

At what time of day is peristalsis the strongest?

A) During the hour after the first meal of the day
B) While sleeping
C) One hour before bedtime
D) During the hour after the last meal of the day

Question 7

The nurse is caring for a patient who has been on bed rest for several weeks.The nurse notes that the patient is continually seeping liquid stool rectally.The nurse should take which action?

A) Hold the patient's antibiotics.
B) Put the patient on a bran diet.
C) Perform a digital rectal examination.
D) Increase the dosage of the patient's antibiotics.

Question 8

While the nurse is administering an enema with a standard enema bag,which intervention is important to implement?

A) Keeping the solution at room temperature
B) Positioning the patient on the right side
C) Raising the enema bag to 30 cm (12 inches)above the patient
D) Instructing the patient to release the enema solution as soon as possible

Question 9

The patient is a 74-year-old man who has been in the hospital for 4 days after an orthopaedic surgical procedure.He is concerned because he has not moved his bowels every day as he did before surgery,but every other day.Which response made by the nurse is appropriate?

A) Advise the patient to put himself on over-the-counter laxatives.
B) Instruct the patient that daily bowel movements are not always necessary.
C) Educate the patient that with increasing age,his bowel movements should increase in frequency.
D) Inform the patient that he will call to get a laxative to get him back on track.

Question 10

When developing a plan of care for a patient requiring a nasogastric (NG)tube,the nurse recognizes that it is essential to implement which technique in measuring the length of the tube?

A) Measure from the nose to the earlobe to the patient's navel.
B) Measure from the nose to the earlobe to the patient's xiphoid process of sternum.
C) Measure and mark a point 76 cm (30 inches)from the end.
D) Measure from the nose to the patient's navel.

Question 11

A(n)___________ is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.

A) fecal impaction
B) intubation
C) enema
D) suppository

Question 12

The nurse has been directed to provide an enema for an elderly female patient who has very poor rectal sphincter control.Which position is most appropriate for this patient?

A) Sims' position
B) Dorsal recumbent position on the bedpan
C) Sitting on the toilet
D) Right lateral position

Question 13

A bedpan that is designed for patients with body or leg casts or for patients restricted from raising their hips (e.g.,after total joint replacement)is known as a _____________.

A) regular pan
B) fracture pan
C) Simons pan
D) tapered pan

Question 14

The patient is being prepped for surgery and has a prescription for "enemas until clear." The nurse realizes that he or she will be giving a maximum of how many enemas?

A) One
B) Two
C) Three
D) Four

Question 15

The nurse is preparing to administer an enema to an adult patient who has normal sphincter control.For administration of the enema,the patient is placed in which position?

A) Right side-lying
B) Dorsal recumbent
C) Sims'
D) Prone

Question 16

The nurse assesses that a patient has a severe fecal impaction.Which action taken by the nurse addresses this problem?

A) Administering laxatives
B) Providing a high-fibre diet
C) Performing a digital removal
D) Administering an enema

Question 17

The nurse prepares to exercise a digital removal of feces.To detect an untoward effect of this procedure,the nurse should assess the patient history for which condition?

A) Heart disease
B) Abdominal pain
C) Urinary infection
D) Diabetes mellitus

Question 18

The nurse is preparing to administer an enema to a patient.Which type of enema is most likely to lead to circulatory overload?

A) Hypertonic solution
B) Soapsuds
C) Tap water
D) Harris flush

Question 19

When evaluating a student nurse's ability to digitally remove feces,the nurse preceptor determined that further teaching is required if the student nurse does which of the following interventions?

A) Provides perianal skin care.
B) Continues the procedure if bleeding starts.
C) Follows the procedure by offering the patient the bedpan.
D) Discontinues the procedure in the presence of bradycardia.

Question 20

When preparing an adult patient for an enema,the nurse understands that the tube or nozzle should be inserted how far?

A) 2.5 to 3.75 cm
B) 5 to 7.5 cm
C) 7.5 to 10 cm
D) 10 to 12.5cm

Question 21

What should the nurse do to verify nasogastric (NG)tube placement? (Select all that apply.)

A) Ask the patient to speak.
B) Inspect the posterior pharynx.
C) Aspirate back on the syringe.
D) Obtain an x-ray examination of the placement.
E) Auscultate the lung fields.

Question 22

A patient is admitted for constipation.When planning care for this patient,the nurse recognizes that which interventions would help control constipation? (Select all that apply.)

A) Increases in activity level
B) Elimination of laxative use
C) Decreased dietary fibre
D) Increased fluids
E) Timely response to urge to move bowels

Question 23

The Levin tube and the Salem sump tube are used most commonly for stomach decompression.Which of the following statements about these tubes is true? (Select all that apply.)

A) Levin tubes have a blue "pigtail" that functions as an air vent.
B) These tubes are inserted as a sterile procedure.
C) The blue air vent should not be used for irrigation.
D) The Salem sump tube has a blue "pigtail" that functions as an air vent.
E) The Salem sump is preferred for stomach decompression.

Question 24

The patient is receiving a soapsuds enema but is having a difficult time retaining the fluid.What action should the nurse take? (Select all that apply.)

A) Give the enema slowly.
B) Place the patient in the dorsal recumbent position on a bedpan.
C) Give the enema with the patient on the toilet.
D) Give the enema in the right lateral position.
E) Give the enema faster.