Chapter 20: Bowel Elimination

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Older and confused b. On cardiac medications c. Chronically constipated d. Has postoperative pain

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?

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment 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°.

3. A student nurse has placed a patient on a bedpan. What assessment requires the faculty to intervene?

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 250–350 mL b. 300–500 mL c. 750–1000 mL d. 1500–1800 mL

4. A student nurse is preparing to administer a cleansing enema to an adult patient. How much fluid does the student anticipate needing for one enema?

ANS: C

For an adult the appropriate amount of solution is 750–1000 mL. A toddler would need 250–350 mL and a school-age child needs 300–500 mL. 1500–1800 mL is too much.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Have the patient sit on the toilet for the enema. b. Give the enema while the patient is on a bedpan. c. Use a fecal management system instead. d. Slow the infusion rate and use absorbent pads.

5. The nursing assistive personnel reports to the nurse that a patient getting an enema cannot hold the solution. What recommendation does the nurse provide?

ANS: D

Slowing the infusion rate of the enema might assist the patient in holding the solution in. If the patient still continues to leak solution, use absorbent padding on the bed. Sitting on the toilet can damage rectal mucosa. Sitting on the bedpan is impractical. The fecal management system is for severe diarrhea.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Uses the index finger to guide the tube’s placement. b. Inflates the cuff balloon prior to insertion. c. Inflates the cuff with 75 mL of saline. d. Attaches collection bag after tube is inserted.

6. The nurse is inserting a fecal management system for a patient with severe diarrhea. What action shows good technique during this procedure?

ANS: A

When inserting the cuff of the tube, the nurse uses the index finger as a guide. The cuff is inflated with 45 mL of water after the cuff is in place. The system is set up before it is inserted with the collection bag attached to the tubing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. On anticoagulants. b. Has severe hemorrhoids. c. Is 13 years of age. d. Has Clostridium difficile diarrhea.

7. The nurse is caring for several patients with severe diarrhea. Which patient is an appropriate candidate for the fecal management system?

ANS: D

The patient with C. diff can develop severe diarrhea with incontinence of stool. This patient is the appropriate candidate for this treatment. The other patients have contraindications for use of the fecal management system.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning 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 how the nurse will ensure privacy and safety.

8. 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?

ANS: D

The nurse increases the likelihood of the patient using the bedpan by explaining how the he or she ensures safety and privacy while the patient uses it. The nurse places the nurse call system and other items that the patient needs or wants within easy reach, covers the patient sufficiently for privacy and warmth, pulls the privacy curtain, and prevents other people from entering the room while the patient sits on the bedpan. Telling the patient that is the only alternative is not really helpful. Hiding the bedpan is deceitful and defeats the purpose of placing it at the bedside if the patient has a sudden stool. Comparing the patient to other patients to induce cooperation shames the patient and is improper; in addition, it denies the patient the right to information and informed consent.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation 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.

9. A patient in skeletal traction for a fractured pelvis needs to use the bedpan. Which technique does the nurse use to position the patient on the bedpan?

ANS: B

If the patient is able to use the feet to lift the hips, this will be the easiest way to get the bedpan under the patient. The nurse may also help lift the patient’s hips. Logrolling may or may not be allowed. The nurse would not disrupt the traction. Warming the bedpan is comforting but doesn’t make positioning easier.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. An NG tube eases distention and nausea. b. The tube can sample gastric secretions. c. It causes peristalsis to return more quickly. d. It prevents vomiting from ever occurring.

10. The nurse prepares to insert a nasogastric (NG) tube into a patient. Which explanation does the nurse give to the patient to explain the use of the NG tube?

ANS: A

The nurse explains to the patient that the NG tube removes gastric contents to decompress the stomach, relieving nausea and distention. The tube gives the gastrointestinal tract a chance to rest before oral nutrition resumes. The tube is not small, nor thin, nor is it predominantly used to sample gastric contents. The NG tube does not stimulate peristalsis. It only removes gases and fluid. With the tube properly placed and functioning, vomiting should not occur, but the nurse should never guarantee that it won’t ever occur.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. In high Fowler’s position b. In left lateral Sims’ position c. Leaning forward on the over-bed table d. Any position that is comfortable

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

ANS: A

The nurse instructs the patient to sit upright and lean back slightly to facilitate passage of the NG tube because, if the patient starts to cough and gag during the insertion, he or she will be in the optimum position already. This position also enhances the patient’s ability to swallow and gravity can partially aid in the tube’s passage. The nurse avoids instructing the patient to assume reclining and left lateral positions because they increase the risk of patient aspiration during the procedure. The nurse instructs the patient to assume the proper position for the procedure because he or she is responsible for the outcome and for facilitating passage of the tube.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use a small-diameter tube. b. Apply lubricant to the NG tube. c. Instruct the patient to bear down. d. Assess the patency of both nostrils.

12. During the insertion of the nasogastric (NG) tube into a patient’s left nares, the nurse meets strong resistance. What action by the nurse would have minimized the chance that this problem would occur?

ANS: D

To prevent tissue trauma and minimize patient discomfort during NG tube insertion, the nurse assesses the patency of both nares before insertion. This helps the nurse determine which naris is more patent and the best naris to use for the initial attempt. If the prescription calls for an NG tube, a small-diameter tube is unsuitable because a small tube does not allow aspiration of gastric contents. If the nares are obstructed, additional lubricant cannot overcome the obstruction and can cause significant patient trauma if the nurse attempts an insertion. The nurse avoids instructing the patient to bear down during NG tube insertion because the Valsalva maneuver engorges tissue and is more likely to impair passage of the tube.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Restlessness b. Drop in SaO2 c. Nasal pressure d. Mouth breathing

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

ANS: B

A drop in SaO2 indicates that the tube has entered the patient’s airway. Patient restlessness and fidgeting should diminish after NG tube placement, especially if the tube helps to relieve nausea and abdominal distention. However, restlessness could be associated with a different problem. The patient is expected to feel some nasal pressure after tube placement; however, the pressure should dissipate with time as the patient adjusts to it. The nurse should assess the naris and surrounding skin per agency policy to ensure no tissue damage occurs. Patients often breathe through the mouth after NG tube placement initially until adjusting to the tube in the nose.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Measure the pH of the gastric aspirate. b. Ask the patient if the tube is comfortable. c. Instill air and listen over the stomach. d. Advance the tube past the measured length.

14. The nurse inserts a nasogastric (NG) tube to the measured length. Which method is the best way to confirm placement of the NG tube without an x-ray film?

ANS: A

N

After inserting the NG tube to the measured length, the nurse asks the patient to speak, visualizes the tube in the posterior oropharynx, and analyzes the gastric aspirate for pH. If the tube is in the esophagus, the patient should be able to speak, the tube should be aligned with the esophagus, and the pH should be less than 4.0. The NG tube is usually uncomfortable initially. The nurse avoids instilling air into the tube as a method of confirming placement because the tube can be in the lungs. Air injected into the stomach increases patient discomfort and gastric distention. The tube is advanced after initial placement assessments when confirmation indicates that it is not in the trachea but potentially has not reached the stomach.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Irrigate the tube with 50 mL of water. b. Assess the patency of the NG tube. c. Replace the NG tube with a larger tube. d. Elevate the patient’s head and reassess.

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

ANS: B

The nurse should assess NG tube patency and drainage from the last few hours to gather additional information about the patient’s nausea. If the NG tube drains 400 mL/day, it should drain 15–20 mL/hr; thus the nurse can observe for drainage. The nurse irrigates the NG tube after confirming its placement. Tube irrigation helps to prevent accumulated debris that increases the risk of tube occlusion. The nurse avoids relieving the patient’s problem with a larger-gauge NG tube; he or she inserted a properly sized tube in the patient. Raising the head of the bed is a reasonable response to help facilitate gastric emptying; however, because the patient has an NG tube, the nurse should verify tube placement first to avoid potential aspiration of gastric contents.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment 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.

16. 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?

ANS: D

The nurse secures the NG tube in place by anchoring it without pressure on the tip of the nares so pressure points do not develop. The nurse avoids alternating NG tube placement daily because tube insertion is uncomfortable and routine changing is not indicated. He or she provides oral care every 2–3 hours to maintain moist, intact oral mucosa and help to prevent patient infection. The head of the bed is elevated to prevent aspiration and minimize irritation from swallowing since the tube is irritating.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Observe sterile technique for each irrigation. b. Inject 50 mL of warm tap water into the tube. c. Gently instill 30 mL of normal saline solution. d. Delegate the procedure to nursing assistive personnel (NAP).

17. The nurse prepares to irrigate a patient’s nasogastric (NG) tube. Which intervention does the nurse implement to irrigate the NG tube?

ANS: C

The nurse instills normal saline solution to irrigate the NG tube to maintain fluid and electrolyte balance and minimize electrolyte depletion from hypotonic fluids. The nurse uses clean technique for irrigating. Water is not recommended for NG irrigation. Irrigating the NG tube is a nursing task that the nurse cannot delegate because it requires clinical judgment and critical thinking skills.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 30 mL b. 160 mL c. 110 mL d. 210 mL

18. 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?

ANS: B

The patient’s 8-hour intake is 160 mL, obtained by adding 50 mL of saline  2, 30 mL of lactulose, and 30 mL of saline to equal 160 mL.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Restless, confused, without bowel sounds b. Difficulty swallowing from left-sided stroke c. Not passing gas with lack of appetite d. Incisional pain after gastric surgery

19. The nurse is caring for four patients. Which patient’s assessment information supports the nurse’s decision to remove the nasogastric (NG) tube after the health care provider writes the order?

ANS: D

Incisional pain is not a reason to maintain a nasogastric tube. The nurse manages the patient’s pain with analgesic, keeping in mind that opioids usually lead to constipation. The restless patient and the patient with dysphagia are at high risk for aspiration because the patient potentially cannot protect the airway and needs the NG tube to help prevent aspiration of gastric contents. The patient who is not passing gas and is experiencing anorexia is not a suitable candidate for NG tube removal because lack of intestinal gas indicates peristaltic impairment. The anorexia is a logical sequela of impaired peristalsis because patients lose their appetites with gastric paresis.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation 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.

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

ANS: D

The nurse teaches the patient that the procedure takes a few seconds and usually causes little discomfort. He or she can also mention that tissues and a warm face cloth are provided after the procedure for patient comfort. The nurse encourages the patient to blow his or her nose after removing the tube. The nurse removes the tube in a smooth and steady motion and avoids medicating the patient unless it is indicated; removing an NG tube generally is not an indication for analgesia. The nurse avoids telling the patient that the procedure is painless because he or she cannot guarantee it and avoids making false promises.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation 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

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

ANS: B

The nurse clamps the NG tube and pulls it out smoothly and steadily, clamps the tube to prevent aspiration of drainage, and helps to prevent aspiration by instructing the patient to hold his or her breath during removal. Deep inhalation can increase the risk for aspiration if it is ill timed. The nurse turns off the suction during the procedure to avoid tissue trauma and decreasing the patient’s oxygenation. The right-handed nurse stands on the patient’s right side to remove the NG tube; this is not a safety maneuver but is for the nurse’s convenience.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation 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.

22. The nurse is preparing to insert a nasogastric (NG) tube in an adult patient. Which technique does the nurse use to measure the length of the tube before gastric intubation?

ANS: D

The nurse measures the patient using the traditional method of measuring from the patient’s nose to the ear to the xiphoid process at the bottom of the sternum. A standard 72-cm (30-inch) length for the NG tube fits some patients and not others; thus this method cannot suitably measure all patients. Measuring to the middle of the sternum results in a short tube, especially since the ear is not involved in the measurement. Measuring to the umbilicus results in an overly long tube.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Withdraw the tube into the posterior pharynx. 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.

23. 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?

ANS: A

Coughing and gagging during NG tube insertion are expected; thus the nurse is prepared to manage the patient’s distress. The nurse withdraws the NG tube into the posterior pharynx and waits until the coughing and gagging stop. The nurse avoids leaving the NG tube in the area that is causing gagging and coughing because he or she wants to help the patient avoid these as much as possible and complete the procedure. To display caring and concern, the nurse avoids just commenting that the gagging will pass and provides meaningful, facilitative instructions. He or she avoids removing the tube because the patient will have to have the procedure started all over again.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning 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.

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

ANS: B

The nurse verifies the nasogastric placement before instilling anything into the tube to prevent fluid instillation into the lungs. Instilling saline solution can help prevent depletion of electrolytes because it is an isotonic fluid; however, the nurse does not implement this before verifying tube placement. The nurse can aspirate the irrigation fluid to prevent fluid volume excess, when the patient is on a fluid restriction, or during the initial insertion. Positioning the patient on the left side can help to prevent aspiration; however, the nurse should verify tube placement before beginning the irrigation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation