BSN 206 - Elimination Sherpaths
Which cue is irrelevant for a patient with constipation?
Expels hard, pebble-like stools
Does not like to exercise
Has an abnormal serum creatinine level
Eats low-fiber foods - answerHas an abnormal serum creatinine level
Having an abnormal serum creatinine level is an irrelevant cue for constipation; it is not
a factor or contributing factor to the patient's constipation.
Which relevant cues would the nurse share with the health care provider when
consulting about a patient who has developed constipation? Select all that apply.
Bed linens are soiled with stool.
Graphic record shows no stool in 2 days.
Patient strains while trying to have a bowel movement.
Patient reports urgency and abdominal cramping.
Decreased bowel sounds auscultated. - answerGraphic record shows no stool in 2
days.
The graphic record provides strong evidence supporting constipation and is a relevant
cue to discuss with the health care provider.
Patient strains while trying to have a bowel movement.
Straining while trying to have a bowel movement is a relevant cue to discuss with the
health care provider.
Which patient is at risk for developing an impaction?
One who is immobile
One who is lactose intolerant
One who is infected with Clostridium difficile
One who is receiving enteral feedings - answerOne who is immobile
The patient who is immobile is at risk for developing an impaction.
Rationale: The patient who is lactose intolerant is at risk for developing flatus, not an
impaction. The patient who is infected with Clostridium difficile is at risk for diarrhea, not
an impaction. The patient who is receiving enteral feedings is at risk for diarrhea, not an
impaction.
Which cause would the nurse consider if the patient is experiencing flatulence?
,Unconsciousness
Loss of nerve sensation
Inability of anal sphincters to work properly
Action of bacteria on chyme - answerAction of bacteria on chyme
Action of bacteria on chyme occurs with flatulence because it is a by-product of
digestion.
Which question would the nurse ask to gather cues about drug-related issues for bowel
elimination?
"Are you using any herbal supplements?"
"Do you have any bloating or gas?"
"When did this start?"
"Where is the pain?" - answer"Are you using any herbal supplements?"
Asking about herbal supplements is a drug-related question for bowel elimination.
Which finding would the nurse categorize as an expected finding for an abdominal
assessment?
Presence of visible peristaltic waves
Nonprotruding midline umbilicus
Asymmetrical abdomen
Ascites - answerNonprotruding midline umbilicus
A nonprotruding midline umbilicus is an expected finding.
Which information would the nurse share with the patient about how blood can be
detected in a guaiac test?
A small amount of feces is applied to a special medium for growing microorganisms.
The stool sample is exposed to a special chemical that changes color when blood is
present.
Feces is placed on a slide and visualized under a microscope, noting any blood.
Stool is viewed under special lighting, showing reddish streaks if blood is present. -
answerThe stool sample is exposed to a special chemical that changes color when
blood is present.
A guaiac test uses a stool sample exposed to a special chemical that changes color
when blood is present.
Which action by the new nurse while performing an abdominal assessment would cause
the charge nurse to intervene?
Auscultates before palpates
Turns off the nasogastric suction while auscultating
Palpates a pulsating midline mass
Communicates with the patient in a matter-of-fact manner - answerPalpates a pulsating
midline mass
The charge nurse would intervene because this is an incorrect action by the new nurse.
If a pulsating midline mass is observed, the nurse would not palpate. This could be an
aneurysm (weak, bulging area in an artery). Palpating this mass may cause the
aneurysm to burst, causing bleeding.
, Which action would the nurse take when performing an abdominal assessment?
Interviews the patient after the physical assessment
Palpates the area of pain last
Percusses the abdomen routinely
Auscultates with cooled stethoscope - answerPalpates the area of pain last
The nurse palpates the area of pain last to prevent discomfort of the patient and to
prevent the abdomen from tightening.
Which expected assessment cue would the nurse find upon palpation of the abdomen?
Hard
Rough
Painless
Mass-filled - answerPainless
Painless is an expected assessment cue; an expected assessment cue for an abdomen
will have no pain upon palpation.
Which diagnostic study would help determine whether there is bleeding in the patient's
stomach?
Barium enema
Lower gastrointestinal (GI) series
Esophagogastroduodenoscopy
Colonoscopy - answerEsophagogastroduodenoscopy
The esophagogastroduodenoscopy would help determine bleeding because it visualizes
the stomach, as well as the mouth, throat, and part of the small intestine.
Which information would the nurse include in a teaching session about a lower
gastrointestinal (GI) series?
Barium is swallowed.
It is a type of radiographic (x-ray) study.
A colonoscope will be inserted into the rectum.
The stool sample will turn blue if there is blood present. - answerIt is a type of
radiographic (x-ray) study.
A lower GI series is a type of radiographic (x-ray) study, so the nurse would include this
information in the teaching session.
Which cues would be anticipated in a patient with flatulence and bloating?
Select all that apply.
Abdominal tenseness on palpation
Visible peristaltic waves
Feelings of nausea
Reports passing excessive gas through the rectum
Reports of abdominal pressure - answerAbdominal tenseness on palpation
Abdominal tenseness on palpation is a cue for flatulence and bloating.
Which cue is irrelevant for a patient with constipation?
Expels hard, pebble-like stools
Does not like to exercise
Has an abnormal serum creatinine level
Eats low-fiber foods - answerHas an abnormal serum creatinine level
Having an abnormal serum creatinine level is an irrelevant cue for constipation; it is not
a factor or contributing factor to the patient's constipation.
Which relevant cues would the nurse share with the health care provider when
consulting about a patient who has developed constipation? Select all that apply.
Bed linens are soiled with stool.
Graphic record shows no stool in 2 days.
Patient strains while trying to have a bowel movement.
Patient reports urgency and abdominal cramping.
Decreased bowel sounds auscultated. - answerGraphic record shows no stool in 2
days.
The graphic record provides strong evidence supporting constipation and is a relevant
cue to discuss with the health care provider.
Patient strains while trying to have a bowel movement.
Straining while trying to have a bowel movement is a relevant cue to discuss with the
health care provider.
Which patient is at risk for developing an impaction?
One who is immobile
One who is lactose intolerant
One who is infected with Clostridium difficile
One who is receiving enteral feedings - answerOne who is immobile
The patient who is immobile is at risk for developing an impaction.
Rationale: The patient who is lactose intolerant is at risk for developing flatus, not an
impaction. The patient who is infected with Clostridium difficile is at risk for diarrhea, not
an impaction. The patient who is receiving enteral feedings is at risk for diarrhea, not an
impaction.
Which cause would the nurse consider if the patient is experiencing flatulence?
,Unconsciousness
Loss of nerve sensation
Inability of anal sphincters to work properly
Action of bacteria on chyme - answerAction of bacteria on chyme
Action of bacteria on chyme occurs with flatulence because it is a by-product of
digestion.
Which question would the nurse ask to gather cues about drug-related issues for bowel
elimination?
"Are you using any herbal supplements?"
"Do you have any bloating or gas?"
"When did this start?"
"Where is the pain?" - answer"Are you using any herbal supplements?"
Asking about herbal supplements is a drug-related question for bowel elimination.
Which finding would the nurse categorize as an expected finding for an abdominal
assessment?
Presence of visible peristaltic waves
Nonprotruding midline umbilicus
Asymmetrical abdomen
Ascites - answerNonprotruding midline umbilicus
A nonprotruding midline umbilicus is an expected finding.
Which information would the nurse share with the patient about how blood can be
detected in a guaiac test?
A small amount of feces is applied to a special medium for growing microorganisms.
The stool sample is exposed to a special chemical that changes color when blood is
present.
Feces is placed on a slide and visualized under a microscope, noting any blood.
Stool is viewed under special lighting, showing reddish streaks if blood is present. -
answerThe stool sample is exposed to a special chemical that changes color when
blood is present.
A guaiac test uses a stool sample exposed to a special chemical that changes color
when blood is present.
Which action by the new nurse while performing an abdominal assessment would cause
the charge nurse to intervene?
Auscultates before palpates
Turns off the nasogastric suction while auscultating
Palpates a pulsating midline mass
Communicates with the patient in a matter-of-fact manner - answerPalpates a pulsating
midline mass
The charge nurse would intervene because this is an incorrect action by the new nurse.
If a pulsating midline mass is observed, the nurse would not palpate. This could be an
aneurysm (weak, bulging area in an artery). Palpating this mass may cause the
aneurysm to burst, causing bleeding.
, Which action would the nurse take when performing an abdominal assessment?
Interviews the patient after the physical assessment
Palpates the area of pain last
Percusses the abdomen routinely
Auscultates with cooled stethoscope - answerPalpates the area of pain last
The nurse palpates the area of pain last to prevent discomfort of the patient and to
prevent the abdomen from tightening.
Which expected assessment cue would the nurse find upon palpation of the abdomen?
Hard
Rough
Painless
Mass-filled - answerPainless
Painless is an expected assessment cue; an expected assessment cue for an abdomen
will have no pain upon palpation.
Which diagnostic study would help determine whether there is bleeding in the patient's
stomach?
Barium enema
Lower gastrointestinal (GI) series
Esophagogastroduodenoscopy
Colonoscopy - answerEsophagogastroduodenoscopy
The esophagogastroduodenoscopy would help determine bleeding because it visualizes
the stomach, as well as the mouth, throat, and part of the small intestine.
Which information would the nurse include in a teaching session about a lower
gastrointestinal (GI) series?
Barium is swallowed.
It is a type of radiographic (x-ray) study.
A colonoscope will be inserted into the rectum.
The stool sample will turn blue if there is blood present. - answerIt is a type of
radiographic (x-ray) study.
A lower GI series is a type of radiographic (x-ray) study, so the nurse would include this
information in the teaching session.
Which cues would be anticipated in a patient with flatulence and bloating?
Select all that apply.
Abdominal tenseness on palpation
Visible peristaltic waves
Feelings of nausea
Reports passing excessive gas through the rectum
Reports of abdominal pressure - answerAbdominal tenseness on palpation
Abdominal tenseness on palpation is a cue for flatulence and bloating.
