TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 20: Bowel Elimination Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nursing assistive personnel (NAP) informs the nurse that the patient with a nasogastric
tube has a reddened area on the naris. What action by the nurse is best? a. Remove the tube and assess the patient for nausea and distention. b. Instruct the NAP to clean off the holding device and apply a new one. c. Assess the patient’s skin condition and reposition the tube at the naris. d. Request a consultation by the Wound Ostomy and Continence Nurse. ANS: C
Device-related pressure ulcers are possible from an NG tube. The nurse would assess the patient and possibly reposition the tube at the naris. The nurse does not remove an NG tube without an order. Applying a new securement device will not help the patient’s skin if the problem is the tube pushing against the naris. The nurse may need to consult the Wound Ostomy and Continence Nurse, but the nurse’s own assessment comes first. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. A nurse and nursing assistive personnel are working with four patients who need enemas.
Which patient is the priority for the nurse to assess before and after the procedure? a. Older and confused b. On cardiac medications N c. Chronically constipated d. Has postoperative pain ANS: B
The nurse would assess the patient on cardiac medications before and after the enema, because enemas and other types of rectal tissue manipulation can cause a vagal response. The patient might become dizzy and faint from his or her heart rate slowing down. The nurse would assess all patients but the one on cardiac medications would be the priority. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
3. A student nurse has placed a patient on a bedpan. What assessment requires the faculty to
intervene? a. The fracture pan has the deep, lower open end under the back. b. The patient has helped lift the hip by using overhead traction. c. The rim of the regular bedpan is towards the foot of the bed. d. The head of the patient’s bed is raised to 30°. ANS: A
For a fracture pan, the deep, lower, open end goes toward the foot of the bed. The other assessments show good care by the student. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
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