1. The nurse observes that Joan’s abdomen is firm and distended. The nurse performs an abdominal assessment. In what sequence should the nurse perform the abdominal assessment?
A. Auscultation, Inspection, Percussion, Palpation
B. Inspection, Palpation, Auscultation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Percussion, Inspection, Palpation
C. Inspection, Auscultation, Percussion, Palpation

Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.

2. Which assessment is most important for the nurse to perform?
A. Auscultate bowel sounds.
B. Measure abdominal girth.
C. Observe incisional staples.
D. Measure bloop pressure
A. Auscultate bowl sounds.
Based on subjective data by Joan (bloated and nauseated) and objective data by the nurse (abdomen firm and distended), the nurse’s first concern is that Joan may have decreased peristalsis.
3. In assessing bowl sounds, it is most important for the nurse to perform which action?
A. Ask the client when she had her last bowel movement.
B. Listen for up to 5 minutes when auscultating the bowl sounds.
C. Perform a rectal exam.
D. Place client in knee-chest position to expel excess gas prior to auscultation.
B. Listen for up to 5 minutes when auscultating for bowel sounds.

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The nurse must listen for up to 5 minutes before determining what type of bowl sounds are present.

4. The nurse auscultates for Joan’s bowel sounds and hears faint gurgling sounds after 3 minutes. How will the nurse record this finding?
A. Hypoactive bowel sounds.
B. Normal bowel sounds.
C. Paralytic ileus.
D. Reduced peristalsis.
A. Hypoactive bowel sounds.

Normally, bowel sounds are heard 5-35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive.

5. While the nurse is completing the assessment, Joan begins to cry and laments, “I just knew something would go wrong.” How should the nurse respond?
A. “This is a minor problem. We’ll have you better very soon.”
B. “You have to expect that problems will occur after surgery.”
C. “Tell me what is making you feel so upset.”
D. “Why are you letting this upset you?”
C. “Tell me what is making you fell so upset.”

This open-ended statement encourages the client to express further concerns and fears.

6. Which response by the nurse will encourage continued verbalization by the client?
A. “All the nurses are very busy here, and they are doing the best job they can.”
B. “You should write down your questions so you can get some answers.”
C. “I will be happy to tell you everything that’s happening, so nothing else will go wrong.”
D. “It sounds as if you have had another experience that did not go well.”
D. “It sounds as if you have had another experience that did not go well.”

The nurse’s response validates Joan’s feelings, which will encourage Joan to verbalize further.

7. How should the nurse respond?
A. Refer to the client to the surgeon to answer any questions about the surgical outcome.
B. Advise the client that an incarcerated hernia is repaired to improve peristalsis so an error must have occurred during the surgery.
C. Offer the client emotional support as she copes with this adverse outcome of surgery.
D. Explain to the client the multiple factors that can decrease peristalsis postoperatlively, even when the desired surgical outcome is achieved.
D. Explain to the client the multiple factors that can decrease peristalsis postoperatlively, even when the desired surgical outcome is achieved.

Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis.

8. The nurse explains to Joan that she has developed constipation, probably as the result of a number of factors. Joan has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 ml. The nurse explains risk factors that can contribute to constipation. Which postoperative medication is most likely to contribute to constipation?
A. Morphine sulfate, an opioid analgesic.
B. Ibuprofen (Advil), a non-opioid analgesic.
C. Promethazine (Phenergan), an antiemetic.
D. Cefazolin (Ancef), an antibiotic.
A. Morphine sulfate, an opioid analgesic.

The most common adverse effect of opioid analgesics is constipation.

9. What impact does this fluid intake have on Joan’s bowel patterns?
A. This inadequate fluid intake has contributed to her constipation.
B. This sufficient amt. of fluid intake has not affected her bowel patterns.
C. This large amount of fluid intake has helped keep her feces soft.
D. Intravenous fluids have little or no impact on intestinal contents and bowel patterns.
A. This inadequate fluid intake has contributed to her constipation.

An adult needs 1,400 to 2,000 ml of fluid daily to prevent hardening of the stool.

10. What other questions should the nurse ask Joan?
A. “How often do you get out of bed and walk?”
B. “Are you using your incentive spirometer regularly?”
C. “When was your abdominal dressing last changed?”
D. “Are you wearing your compression devices while in bed?”
A. “How often do you get out of bed and walk?”

Immobility is a major risk factor for constipation.

11. The nurse revises Joan’s plan of care to include postoperative constipation. Before establishing the diagnostic statement, the nurse needs to complete which task?
A. Plan the desired outcome and goal of care.
B. Determine which factor is causing the problem.
C. Consider possible nursing actions to resolve the problem.
D. Consult with the healthcare provider regarding the risk factors involved.
B. Determine which factor is causing the problem.

The cause of the problem should be determined since this is a component of the diagnostic statement.

12. The nurse determines that Joan’s inadequate fluid intake, decreases mobility, an opiod use are significant factors in the development of her constipation. Which nursing diagnosis should the nurse include in Joan’s plan of care?
A. Risk for constipation and lack of fluid intake.
B. Inadequate fluid intake, resulting in constipation.
C. Constipation related to surgery and anesthesia.
D. Constipation as manifested by decreased bowel sounds.
C. Constipation related to surgery and anesthesia.

This diagnostic statement uses the correct format and identifies both the problem and the etiology.

13. The nurse explains that the glycerin suppository will have a laxative effect. How will the nurse explain to Joan the action of the laxative?
A. “The stool will be broken up so that it will be small enough to be expelled from your rectum.”
B. “Movement of the intestine will push the bowl contents out so you will have a bowl movement.”
C. “The hard stool will be softened so you will not have to strain to have a bowl movement.”
D. “You may experience abdominal cramping and may even have some diarrhea as the result of this medication.”
B. “Movement of the intestine will push the bowl contents out so you will have a bowl movement.”

Laxatives stimulate peristalsis so that the bowl contents can then be expelled.

14. The nurse explains to Joan that her healthcare provider has prescribed 2 medications: a one-time dose of glycerin (Fleets) rectal suppository and docusate sodium (Surfak) 100mg PO daily. The nurse administers the first dose of the docusate sodium (Surfak). This med. primarily alters which aspect of the client’s bowel movement?
A. Color.
B. Amount.
C. Frequency.
D. Consistency.
D. Consistency.

Surfak is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.

15. Before administering the rectal suppository, it is most important for the nurse to perform which assessment?
A. Ask about the client’s normal bowel patterns.
B. Monitor the client’s blood pressure and pulse.
C. Determine if the client has any hemorrhoids.
D. Observe for the presence of rectal bleeding.
D. Observe for the presence of rectal bleeding.

The administration of a rectal suppository is generally contraindicated in the presence of rectal bleeding, so this assessment is the most important.

16. When administering the rectal suppository, the nurse asks Joan to take several slow, deep breaths. What is the rationale for this instruction?
A. Distract Joan from the suppository insertion.
B. Relax the anal sphincter and reduce discomfort.
C. Improve intestinal peristalsis and motility.
D. Reduce spasms from hemorrhoids.
B. Relax the anal sphincter and reduce discomfort.

Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.

17. The nurse documents the administration of the rectal suppository in the nurses’ notes. Which notation is correct?
A. 0900. Lubricant used when one glycerin suppository inserted.
B. 0900. One suppository inserted because of constipation.
C. 0900. One glycerin suppository administered per rectum for constipation, as prescribed.
D. 0900. One laxative (glycerin) administered for constipation.
C. 0900. One glycerin suppository administered per rectum for constipation, as prescribed.

This documentation correctly ID’s the med, the dose, the time, and the route of administration, as well as teh reason for administering the med.

18. Which statement provided the best documentation of the outcome from the suppository administration?
A. Client reports that the suppository was not helpful in relieving constipation.
B. Client produced six 1/4 inch hard pellets of brown stool following suppository administration.
C. Client will need additional treatment to resolve problem of constipation.
D. Dulcolax suppository administration produced only a small amount of feces.
B. Client produced six 1/4 inch hard pellets of brown stool following suppository administration.

This documentation provided the most specific objective data related to the effectiveness of the suppository.

19. The next day, Joan still has not expelled additional feces. To determine the presence of fecal impaction, the nurse prepare Joan for which prescribed procedure?
A. Insertion of a rectal tube.
B. Enema administration.
C. Digital rectal examination.
D. Sigmoidoscopy.
C. Digital rectal examination.

Digital rectal exam is the procedure performed to assess for the presence of a fecal impaction.

20. The unlicensed assistive personnel (UAP) obtains sterile gloves and lubricant of the nurse and offers to perform the procedure since the nurse is busy. What action should the nurse implement?
A. Tell the UAP to perform the procedure using the lubricant, but advise her that the use of sterile gloves is not necessary.
B. Perform the procedure using the supplies obtained by the UAP.
C. Commend the UAP for her willingness to help and ask her to leave the supplies for the healthcare provider, who must perform the procedure.
D. Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed.
D. Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed.

This task should not be delegated to the UAP because it is an invasive procedure that places the client at risk. The UAP can be assigned to assist the nurse with client positioning. Assisting in this manner provides an opportunity for the nurse to teach the UAP that this is not sterile procedure. The nurse should use nonsterile exam gloves, which are less costly than sterile gloves, and lubricant for this procedure.

21. While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?
A. Increased blood pressure.
B. Increased temperature.
C. Decreased respirations.
D. Decreased pulse rate.
D. Decreased pulse rate.

Vagal nerve stimulation can cause a reflex slowing of the heart rate.

22. The nurse notifies the healthcare provider of the presence of a fecal impaction and receives a verbal prescription over the telephone for enema administration. What action should the nurse take?
A. Wait to administer the enema until the healthcare provider is able to sign the prescription in person.
B. Administer the enema as prescribed and obtain the healthcare provider’s signature the next day.
C. Explain to the healthcare provider that verbal prescriptions are not legally defensible, and a written prescription is needed.
D. Ask the charge nurse to assist with preparing a variance report to explain the use of verbal prescription.
B. Administer the enema as prescribed and obtain the healthcare provider’s signature the next day.

A verbal Rx is legally permissible. The nurse should, however, take measures to ensure client safety b/c verbal Rx’s can be a source of error. The nurse should read back the complete Rx and have the verbal Rx signed w/i 24hrs. Some healthcare agencies do not allow verbal Rx’s, so it is important for the nurse to adhere to agency policy.

23. When receiving the verbal Rx over the phone, the nurse repeats the Rx back to the healthcare provider, who sounds angry and state, “Are you questioning my prescription?” How should the nurse respond to the provider?
A. “Make sure you sign this verbal Rx w/i 24 hours.”
B. “I want to ensure that I transcribe this Rx correctly to avoid error.”
C. “You should be glad I want to ensure the accuracy of this Rx”
D. “I have the responsibility to question any Rx’s I do not feel are correct.”
B. “I want to ensure that I transcribe this Rx correctly to avoid error.”

This assertive response teaches the healthcare provider the purpose of repeating back verbal Rx’s.

24. The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Joan begins to experience abdominal cramping. What action(s) should the nurse take to relieve the abdominal cramping? (Select all that apply)
A. Raise the head of the bed.
B. Lower the enema bag.
C. Assess the client’s vital signs.
D. stop the enema and assist Joan to the bathroom.
E. Roll the clamp to stop enema until cramping subsides.
B. Lower the enema bag.

Lowering the enema bag will slow or stop the flow of fluid, which should reduce or stop the client’s abdominal cramping.

E. Roll the clamp to stop enema until cramping subsides.

This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.

Joan has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Joan, the nurse receives a report from the UAP that another client is vomiting. The nurse tells Joan she will return as soon as she deals with the other client’s problem. What task can the nurse delegate to the UAP?
A. Decide if Joan needs another enema.
B. Give the vomiting client an antiemetic.
C. Teach Joan how to self-administer the enema.
D. Assist the client who vomited with mouth care and bathing after the nurse administers the antiemetic.
D. Assist the client who vomited with mouth care and bathing after the nurse administers the antiemetic.

Hygiene and comfort care are both w/i the UAP’s scope of practice.

26. The nurse assesses the client who is vomiting and acts to alleviate this problem. She returns to Joan’s room. Joan is interested in the amount of fluid administered via the enema but does not understand “milliliters.” Joan received a total volume of 725 ml. How will then nurse accurately explain the amount of fluid to Joan using household measurements.
A. 3 cups.
B. 6 cups.
C. 1 quart.
D. 1/2 gallon.
A. 3 cups.
The conversion factors needed are: 30ml=1oz, and 1 cup=8oz. 725 ml/30=24 oz/8 =3 cups.
The nurse wants Joan to increase her daily oral fluid intake to 2 liters of fluid for the next few days. The nurse advises Joan to drink a minimum of how many 8-oz cups of fluid daily?
A. 4-5
B. 6-7
C. 8-9
D.10-12
C. 8-9.

One 8-oz cup contains 240 ml (8×30 ml/oz). Two liters=2000ml. 2000ml/240ml=8.33 cups/day.

28. The remainder of Joan’s surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Joan eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity. She states that she really likes salads. Which salad choice is best to promote bowel regularity?
A. Fresh fruit salad w/ apple and banana slices.
B. Canned pears w/ low-fat cottage cheese.
C. Tuna salad w/ eggs and mayonnaise.
D. Pasta salad w/pepperoni and ham.
A. Fresh fruit salad w/ apple and banana slices.

Fresh fruits are a good source of fiber, which is important for bowel regularity.

29. The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by Joan indicates that she understands teaching about dietary measures to promote bowel regularity?
A. Toasted bagel w/jam, and skim milk.
B. Pancakes w/ maple syrup, and coffee.
C. Bacon & eggs, & herbal tea.
D. Oatmeal w/ raisins and OJ
D. Oatmeal w/ raisins and OJ

Whole-grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.

Case Outcome:
Joan expresses her thanks to the nurse and states she feels confident in her ability to manage her diet, fluid intake, and activity when she is discharged to ensure regular bowel patterns.
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