GI
A nurse is caring for a patient with a colostomy who has a two-piece ostomy appliance.
Which is important for the nurse to do when caring for this patient? - correct answer-Change
the faceplate of the appliance every 3 to 5 days or when necessary: The adhesive backing
may loosen from the skin beyond 3 to 5 days, allowing leakage underneath the faceplate,
resulting in skin excoriation. A faceplate changed every 3 to 5 days ensures adherence of
the faceplate to the skin.
Which statement by a patient with an ileostomy alerts the nurse to the need for further
education? - correct answer-"I'm going to irrigate my stoma so I have a bowel movement
every morning." : This statement is inaccurate in relation to an ileostomy and indicates that
the patient needs more teaching. An ileostomy produces liquid fecal drainage that is
constant and cannot be regulated.
A nurse is caring for a patient who is recovering from abdominal surgery. The patient reports
experiencing "gas pains" and asks the nurse what can be done to prevent them in the future.
Which should the nurse encourage the patient to avoid until intestinal function fully returns?
Select all that apply. - correct answer-Chewing gum
Onions
Lentils
A practitioner orders a soapsuds enema for an adult patient. The nurse explains the
procedure to the patient and arranges for the bathroom to be available. The nurse then
performs hand washing, collects the equipment, and begins to prepare the enema
equipment. Arrange these interventions in the order in which they should be performed. -
correct answer-The first intervention would be to clamp the tubing, as this allows water to
collect in the container. The section intervention would be to fill the container with 1000 mL
of 110°F water. Soapsuds enema for an adult should be 500 to 1000 mL of water at 105°F to
110°F. The volume is sufficient to distend the intestinal lumen, and the temperature is slightly
more than body temperature to provide for comfort. The third intervention would be to flush
the tubing with water, as this expels air from the tubing, preventing air from entering the
intestine. The fourth intervention would be to add soap to the container, and gently rock the
enema bag to disperse the soap; soap is added after the container is filled to prevent the
formation of bubbles and after the tubing is flushed to ensure that the soap is diluted in the
total volume of solution (3 to 5 mL of soap per 1000 mL of water), while gently rocking the
enema bag prevents bubble formation while dispersing the soap evenly throughout the fluid.
The last intervention would be to lubricate the catheter tip with water-soluble jelly to limit
trauma as the catheter is inserted into the patient's anus and rectum.
A nurse is caring for a patient who was admitted to the hospital because of a fecal impaction.
The nurse identified that inadequate fiber, fluid, and activity contributed to this patient's
problem. In addition, which medication that the patient is taking most likely contributed to the
fecal impaction? - correct answer-Fesol: Constipation is a common side effect of carbonyl
iron (Fesol); iron interferes with myoglobin, which helps provide oxygen to muscles, including
those associated with the bowel, resulting in decreased bowel motility.
A nurse is caring for a patient with a colostomy who has a two-piece ostomy appliance.
Which is important for the nurse to do when caring for this patient? - correct answer-Change
the faceplate of the appliance every 3 to 5 days or when necessary: The adhesive backing
may loosen from the skin beyond 3 to 5 days, allowing leakage underneath the faceplate,
resulting in skin excoriation. A faceplate changed every 3 to 5 days ensures adherence of
the faceplate to the skin.
Which statement by a patient with an ileostomy alerts the nurse to the need for further
education? - correct answer-"I'm going to irrigate my stoma so I have a bowel movement
every morning." : This statement is inaccurate in relation to an ileostomy and indicates that
the patient needs more teaching. An ileostomy produces liquid fecal drainage that is
constant and cannot be regulated.
A nurse is caring for a patient who is recovering from abdominal surgery. The patient reports
experiencing "gas pains" and asks the nurse what can be done to prevent them in the future.
Which should the nurse encourage the patient to avoid until intestinal function fully returns?
Select all that apply. - correct answer-Chewing gum
Onions
Lentils
A practitioner orders a soapsuds enema for an adult patient. The nurse explains the
procedure to the patient and arranges for the bathroom to be available. The nurse then
performs hand washing, collects the equipment, and begins to prepare the enema
equipment. Arrange these interventions in the order in which they should be performed. -
correct answer-The first intervention would be to clamp the tubing, as this allows water to
collect in the container. The section intervention would be to fill the container with 1000 mL
of 110°F water. Soapsuds enema for an adult should be 500 to 1000 mL of water at 105°F to
110°F. The volume is sufficient to distend the intestinal lumen, and the temperature is slightly
more than body temperature to provide for comfort. The third intervention would be to flush
the tubing with water, as this expels air from the tubing, preventing air from entering the
intestine. The fourth intervention would be to add soap to the container, and gently rock the
enema bag to disperse the soap; soap is added after the container is filled to prevent the
formation of bubbles and after the tubing is flushed to ensure that the soap is diluted in the
total volume of solution (3 to 5 mL of soap per 1000 mL of water), while gently rocking the
enema bag prevents bubble formation while dispersing the soap evenly throughout the fluid.
The last intervention would be to lubricate the catheter tip with water-soluble jelly to limit
trauma as the catheter is inserted into the patient's anus and rectum.
A nurse is caring for a patient who was admitted to the hospital because of a fecal impaction.
The nurse identified that inadequate fiber, fluid, and activity contributed to this patient's
problem. In addition, which medication that the patient is taking most likely contributed to the
fecal impaction? - correct answer-Fesol: Constipation is a common side effect of carbonyl
iron (Fesol); iron interferes with myoglobin, which helps provide oxygen to muscles, including
those associated with the bowel, resulting in decreased bowel motility.
