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Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank
Chapter 46: Bowel Elimination
MULTIPLE CHOICE
1. Which of the following would the nurse expect as a normal change in the bowel
elimination as a person ages?
1. Absorptive processes are increased in the intestinal mucosa.
2. Esophageal emptying time is increased.
3. Changes in nerve innervation and sensation cause diarrhea.
4. Mastication processes are less efficient.
ANS: 4
An expected change in bowel elimination is decreased chewing and decreased salivation,
resulting in less efficient mastication. There is decreased nutrient absorption of the small
intestine in the older adult. Esophageal emptying slows, as a result of reduced motility,
especially in the lower third of the esophagus. With decreased peristalsis and weakened
musculature, the older adult is more prone to constipation. Duller nerve sensations may
place the older adult at increased risk for fecal incontinence.
DIF: A
REF: 1177
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
2. An 8-month-old infant is hospitalized with severe diarrhea. The nurse knows that the
major problem associated with severe diarrhea is:
1. Pain in the abdominal area
2. Electrolyte and fluid loss
3. Presence of excessive flatus
4. Irritation of the perineal and rectal area
ANS: 2
Excess loss of colonic fluid because of diarrhea can result in serious fluid and electrolyte
or acid-base imbalances. Infants and older adults are particularly susceptible to associated
complications. Pain from abdominal cramping may occur with diarrhea, but it is not the
major problem associated with severe diarrhea. Excessive flatus is not the major problem
associated with severe diarrhea. Because repeated passage of diarrhea stools exposes the
skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care
and containment of fecal drainage are needed to prevent skin breakdown. The greatest
danger of severe diarrhea is a fluid and electrolyte or acid-base imbalance.
DIF: A
REF: 1180
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
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3. A 50-year-old male client is having a screening colonoscopy. The nurse instructs the
client that:
1. No special preparation is required
2. Light sedation is normally used
3. No metallic objects are allowed
4. Swallowing of an opaque liquid is required
ANS: 2
Light sedation is required for a colonoscopy. Special preparation is required before a
colonoscopy. Clear liquids are given the day before and then some form of bowel
cleanser, such as GoLytely, is administered. Enemas until clear may also be ordered.
There is no restriction of metallic objects for a colonoscopy, not does it require
swallowing an opaque liquid.
DIF: A
REF: 1178
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
4. A client is to have a stool test for occult blood. The nurse is instructing the nursing
assistant in the correct procedure for the test. The nursing assistant is correctly informed
that:
1. Sterile technique is used for collection
2. Stool should be collected over a 3-day period
3. The specimen should be kept warm
4. A 1-inch sample of formed stool is needed
ANS: 4
Tests performed by the laboratory for occult blood in the stool and stool cultures require
only a small sample. The nurse uses clean technique to collect about 1 inch of formed
stool or 15 to 30 mL of liquid stool. Unlike testing for occult blood, tests for measuring
the output of fecal fat require a 3- to 5-day collection of stool, and tests that measure for
ova and parasites require the stool to be warm.
DIF: A
REF: 1188
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
5. A client who recently underwent surgery and now has a colostomy is correctly instructed
by the nurse that for the next few weeks the client's diet will include foods such as:
1. Vegetables
2. Fresh fruit
3. Whole grain breads
4. Poached eggs and rice
ANS: 4
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During the first weeks after surgery, many health care providers recommend low-fiber
diets because the bowel requires time to adapt to the diversion. Low-fiber foods include
bread, noodles, rice, cream cheese, eggs (not fried), strained fruit juices, lean meats, fish,
and poultry. Poached eggs and rice would be appropriate for this client. After the ostomy
heals, the client is allowed to eat whole grains, fruits, and vegetables. High-fiber foods
such as fresh fruits and vegetables help ensure a more solid stool needed to achieve
success at irrigation. Ostomy clients may benefit from avoiding foods that cause gas and
odor, including broccoli, cauliflower, dried beans, and Brussels sprouts.
DIF: A
REF: 1210
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
6. The client has been admitted to an acute care unit with a diagnosis of biliary disease. The
nurse suspects that the feces will appear:
1. Bloody
2. Pus filled
3. Black and tarry
4. White or clay colored
ANS: 4
Stool that is white or clay colored indicates an absence of bile. Bloody feces is not an
indication of biliary disease. Pus-filled feces indicate infection. Black or tarry feces may
indicate upper gastrointestinal (GI) bleeding or iron ingestion.
DIF: A
REF: 1188-1190
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
7. The client asks the nurse to recommend bulk-forming foods that may be included in the
diet. Which of the following should be recommended by the nurse?
1. Whole grains
2. Fruit juice
3. Rare meats
4. Milk products
ANS: 1
Bulk-forming foods, such as grains, fruits, and vegetables, absorb fluids and increase
stool mass. Fruit juice, rare meats, and milk products are not bulk-forming foods.
DIF: A
REF: 1177
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination

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8. The client is taking medications to promote defecation. Which of the following


instructions should be included by the nurse in the teaching plan for this client?
1. Increased laxative use often causes hyperkalemia.
2. Salt tablets should be taken to increase the solute concentration of the extracellular
fluid.
3. Emollient solutions may increase the amount of water secreted into the bowel.
4. Bulk-forming additives may turn the urine pink.
ANS: 3
Emollient solutions are stool softeners that may increase the amount of water secreted
into the bowel. Laxative overuse can cause serious diarrhea that can lead to dehydration
and hypokalemia. Salt tablets should not be taken to increase the solute concentration of
extracellular fluid. Bulk-forming additives do not turn the urine pink. Phenolphthalein or
danthron stimulant cathartics (e.g., Doxidan, Correctol, Ex-Lax) may cause pink or red
urine.
DIF: A
REF: 1198
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
9. While undergoing a soapsuds enema, the client complains of abdominal cramping. The
nurse should:
1. Immediately stop the infusion
2. Lower the height of the enema container
3. Advance the enema tubing 2 to 3 inches
4. Clamp the tubing
ANS: 2
The nurse should lower the container if the client complains of abdominal cramping.
Cramping may prevent the client from retaining all of the fluid, which would alter the
effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of
the fluid, and the enema will be less effective. The nurse may slow the infusion until the
abdominal cramping passes. The enema tubing should not be advanced further. The
tubing may be clamped temporarily if fluid escapes around the rectal tube. The
instillation should be slowed in the instance of abdominal cramping.
DIF: B
REF: 1202
OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
10. A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48
hours postoperatively, clients who have undergone general anesthesia may experience:
1. Colitis
2. Stomatitis
3. Paralytic ileus

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4. Gastrocolic reflex
ANS: 3
Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis.
This condition, called paralytic ileus, usually lasts about 24 to 48 hours. Colitis is
inflammation of the colon. Stomatitis is inflammation of the mouth. The gastrocolic
reflex is the peristaltic wave in the colon induced by entrance of food into the stomach.
Colitis, stomatitis, and gastrocolic reflex are not caused by anesthetic used during
surgery.
DIF: A
REF: 1178
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
11. For clients with hypocalcemia, the nurse should implement measures to prevent:
1. Gastric upset
2. Malabsorption
3. Constipation
4. Fluid secretion
ANS: 3
Disorders of calcium metabolism contribute to difficulty with the passage of stools. The
nurse should implement measures to prevent constipation in clients with hypocalcemia.
Gastric upset, malabsorption, and fluid secretion are not caused by hypocalcemia.
DIF: A
REF: 1179
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
12. The client is to receive a Kayexalate enema. The nurse recognizes that this is used to:
1. Prevent further constipation
2. Remove excess potassium from the system
3. Reduce bacteria in the colon before diagnostic testing
4. Provide direct antidiarrheal medication to the intestine
ANS: 2
Kayexalate is a type of medicated enema used to treat clients with dangerously high
serum potassium levels. This drug contains a resin that exchanges sodium ions for
potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent
constipation, and Kayexalate is not a diarrheal medication. Neomycin enemas, not
Kayexalate enemas, may be used to reduce bacteria in the colon before diagnostic testing.
DIF: A
REF: 1197
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
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13. The appropriate amount of fluid to prepare for an enema to be given to an average-size
school-age child is:
1. 150 to 250 mL
2. 250 to 350 mL
3. 300 to 500 mL
4. 500 to 750 mL
ANS: 3
The appropriate amount of fluid to prepare for an enema to be given to an average-size
school-age child is 300 to 500 mL. An infant should receive 150 to 250 mL, a toddler
should receive 250 to 350 mL, and an adolescent should receive 500 to 750 mL.
DIF: A
REF: 1200
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
14. A client has undergone intestinal surgery and now has an incontinent ostomy. The use of
which of the following products by the client indicates that the discharge learning goals
have been achieved?
1. A powder for a yeast infection
2. Peroxide to toughen the peristomal skin
3. A commercial deodorant around the stoma
4. Alcohol to cleanse the stoma
ANS: 1
If a yeast infection occurs, thorough cleansing should be performed, followed by patting
the area dry and applying a prescribed topical agent, such as triamcinolone acetonide
(Kenalog) spray or nystatin (Mycostatin), to the affected region. The peristomal skin
should be cleansed gently with warm tap water using gauze pads or a clean washcloth. An
ostomy deodorant may be placed into the pouch, not around the stoma. Alcohol should
not be used to clean the stoma. The area may be cleaned with warm tap water.
DIF: A
REF: 1217
OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
15. Which of the following is an appropriate nursing intervention for a client with a
nasogastric tube in place?
1. Tape the tube up and around the ear on the side of insertion.
2. Secure the tubing to the bed by the clients head.
3. Mark the tube where it exits the nose.
4. Change the tubing daily.
ANS: 3

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Once placement is confirmed, a mark should be placed, either making a red mark or
using tape, on the tube to indicate where the tube exits the nose. The mark or tube length
is to be used as a guide to indicate whether displacement may have occurred. The tube
should be taped to the nose, not to the ear. The tubing should be secured to the clients
gown, not the bed. The tubing should not be changed daily, but it should be irrigated
daily.
DIF: A
REF: 1208
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
16. The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat:
1. Whole wheat bread
2. A lean, T-bone steak
3. Veal
4. Salmon
ANS: 1
Whole wheat bread may be eaten before a fecal occult blood test. A lean, T-bone steak
may cause false-positive results if eaten before a fecal occult blood test. Veal may cause
false-positive results if eaten before a fecal occult blood test. Salmon may cause falsepositive results if eaten before a fecal occult blood test.
DIF: A
REF: 1188
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
17. The nurse is discussing arteriosclerosis and the effects it has on the body with an older
adult client. Although the most commonly recognized effect is on the cardiovascular
system, the nurse should include which of the following statements regarding its effect on
the gastrointestinal system to complete the discussion?
1. Circulatory problems make getting to the bathroom easily problematic.
2. The benefit you get from your food is also decreased by this condition.
3. The aging process that causes the vascular problems also causes elimination
problems.
4. The problem it creates with blood flow also affects blood flow to the bowels and
so affects elimination.
ANS: 4
Systemic changes in the function of digestion and absorption of nutrients result from
changes in older clients cardiovascular and neurological systems, rather than their
gastrointestinal system. For example, arteriosclerosis causes decreased mesenteric blood
flow, thus decreasing absorption from the small intestine.
DIF:

REF: 1177

OBJ: Analysis

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46-8

TOP: Nursing Process: Planning


MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
18. Which of the following statements made by an older adult reflects the best understanding
of the role of fiber regarding bowel patterns?
1. The more fiber I eat, the fewer problems I have with my bowels.
2. Whole grain cereal and toast for breakfast keeps my bowels moving regularly.
3. My wife makes whole grain muffins; they are really good and good for me too.
4. I use to have trouble with constipation until I started taking a fiber supplement.
ANS: 2
The bowel walls are stretched, creating peristalsis and initiating the defecation reflex. By
stimulating peristalsis, bulk foods pass quickly through the intestines, keeping the stool
soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern
if other factors are normal. The other options are not as specific about the role of fiber, or
they fail to provide an example of a high-fiber food.
DIF: C
REF: 1177
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
19. Which of the following statements made by an older adult reflects the best understanding
of the role of fiber regarding good bowel health?
1. Fiber is very effective at cleaning out the bowels.
2. A high-fiber diet results in softer bowel movements.
3. Passing hard, dry stool is more uncomfortable and harder on the bowels.
4. The more fiber there is in my diet, the less risk I have of developing polyps.
ANS: 4
When there is no fiber to transport waste matter through the colon, it increases the risk
for polyps. Although the other options are not incorrect, they do not address the most
important barrier to good bowel health.
DIF: C
REF: 1177
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
20. The nurse is discussing food allergies with a group of mothers whose children are allergy
prone. Which of the following statements made by the nurse best describes lactose
intolerance?
1. If milk causes diarrhea, cramps, or gas, it might be an intolerance of lactose.
2. You dont have to be allergic to dairy for it to cause you problems.
3. Allergies to milk can be very dangerous, even life threatening.
4. Many children outgrow their intolerance of dairy lactose.

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ANS: 1
Food intolerance is not an allergy, but a particular food that causes the body distress
within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For
example, people who drink cows milk who have these symptoms are not allergic to milk
but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant.
DIF: C
REF: 1177
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
21. The nurse is discussing food allergies with a group of mothers whose children are allergy
prone. Which of the following statements made by a mother best describes lactose
intolerance?
1. My child is allergic to milk; it makes her very gassy.
2. Dairy products require a special enzyme to be digested properly.
3. Being lactose intolerant means my child cant tolerate dairy products.
4. My child gets diarrhea from dairy products because she cant digest lactose.
ANS: 4
Food intolerance is not an allergy, but a particular food that causes the body distress
within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For
example, people who drink cows milk who have these symptoms are not allergic to milk
but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant.
To be lactose intolerant (exhibiting the signs after ingesting dairy products) does not
constitute a dairy allergy. The remaining options are not as specific as the answer.
DIF: C
REF: 1177
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
22. An adult client reports to the nurse that she has been experiencing constipation recently
and is interested in any suggestions regarding dietary changes she might make. Which of
the following suggestions provided by the nurse is most likely to minimize the clients
complaint?
1. Have you tried foods like prunes and bran?
2. You might find the new flavored bulk laxatives helpful.
3. What have you tried in the past that hasnt been helpful?
4. Increase your fluid intake; have some juice with breakfast.
ANS: 4

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46-10

Unless there is a medical contraindication, an adult needs to drink six to eight glasses
(1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use
of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk
for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools.
Although some of the options are food related, they are not as direct; a laxative is not a
dietary change.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Physiological Integrity/Basic Care and Comfort/Elimination
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
23. A client who is 2 days' postoperative reports feeling constipated to the nurse. The client
has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is
being controlled with an opioid analgesic. Which of the following interventions should
the nurse try initially?
1. Let me get you some apple juice.
2. Ambulating may get your bowels moving.
3. Ill see about getting a different pain medication.
4. Your health care provider might prescribe an enema if I call.
ANS: 1
An increase in fluid intake with the use of fruit juices softens stool and increases
peristalsis. The remaining interventions are not inappropriate, but they are not the initial
intervention for such a complaint.
DIF: B
REF: 1178
OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
24. Which of the following statements by a client reporting constipation reflects the most
informed understanding of interventions that will aid in assuming proper bowel mobility?
1. Could it be that I need to get more exercise, even here in the hospital?
2. Is it true that drinking coffee often helps stimulate the bowels to work?
3. I guess a little high-fiber cereal might help. Can you get me some from the
cafeteria?
4. May I have a cup of decaffeinated tea in addition to my breakfast juice? That
usually helps.
ANS: 4
Unless there is a medical contraindication, an adult needs to drink six to eight glasses
(1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use
of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk
for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools.
Although the other options are not incorrect, the client does not seem to have past
experience with these suggestions.

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Test Bank

46-11

DIF: C
REF: 1177-1178
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
25. A client is caring for her husband who recently experienced a cerebral vascular accident.
She tells the home care nurse that she has been very anxious lately about all the added
responsibilities. She adds that she has not been sleeping well and has had several bouts of
diarrhea. Which of the following statements by the nurse focuses on the most likely cause
of the gastrointestinal problem?
1. Have you experienced increased gas and cramping in addition to the diarrhea?
2. You are under a lot of stress; that can affect your bowels and result in diarrhea.
3. I suggest you get some over-the-counter medication and keep it on hand to
manage those bouts.
4. Have you been eating a well-balanced diet since you brought your husband
home?
ANS: 2
During emotional stress the digestive process is accelerated, and peristalsis is increased.
Side effects of increased peristalsis are diarrhea and gaseous distention. The remaining
options are focused on the most likely cause of the problem, or they are focused on
treatment, not cause.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Analysis
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
26. A client is caring for her daughter, who recently suffered multiple fractures in an
automobile accident. The client tells the home care nurse that she has been really down
since all this happened. She adds that she has been constipated and not really interested
in eating. Which of the following statements by the nurse focuses on the most likely
cause of the gastrointestinal problem?
1. Actually, how long have you been constipated?
2. Are you eating fiber-rich foods like fruit and whole grains?
3. You may be depressed; emotional depression can cause constipation.
4. I suggest you get some over-the-counter mild laxative and see if that helps.
ANS: 3
If a person becomes depressed, the autonomic nervous system slows impulses, and
peristalsis decreases, resulting in constipation. Although the other options are not
incorrect, they are not the most likely cause for this particular client.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and

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Comfort/Elimination
27. A 70-year-old client is discussing his recent difficulty with having regular bowel
movements while on a cross-country bus tour with a senior citizens group. Which of the
following assessment questions is directed toward the most likely cause of the problem?
1. Did the bus stop frequently so you could get up and walk around?
2. Did you eat enough fiber while you were on the trip?
3. Do you find using public restrooms unsettling?
4. Do you have any chronic bowel-related problems?
ANS: 3
Attempting to eliminate in a public restroom sometimes results in a temporary inability to
defecate. This embarrassment may prompt clients to ignore the urge to defecate, which
begins a vicious cycle of constipation and discomfort. Although the remaining options
may affect bowel elimination, the situation of the scenario strongly suggests an emotional
cause.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
28. The nurse is caring for a 19-year-old male client with a fractured left femur whose leg
was pinned 36 hours ago and is now in traction. Which of the following stressors is
mostly likely the cause of this clients difficulty related to constipation?
1. Pain related to the fracture and its repair
2. Anxiety regarding the serious nature of the injury
3. The need to defecate in an unfamiliar, awkward position
4. Poor fluid intake after the accident and ensuing surgery
ANS: 3
For the client immobilized in bed, defecation is often difficult. In a supine position it is
impossible to contract the muscles used during defecation. If the clients condition
permits, raise the head of the bed; this assists the client to a more normal sitting position
on a bedpan, enhancing the ability to defecate. Although the other options may have some
effect, the primary cause is most likely the emotional stress of not being able to assume
the usual position for defecation.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
29. A client who was recently diagnosed with anemia and rheumatoid arthritis reports to the
nurse that she has noticed that her stool is black, and she is concerned because there is a
history of colon cancer in her family. Which of the following assessment questions is
most likely to provide information regarding this clients bowel problem?

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Test Bank
1.
2.
3.
4.

46-13

What medications are you currently on?


When did you have your last colonoscopy?
Does the arthritis severely impair your mobility?
Would you like to have the stool tested for occult blood?

ANS: 1
Ingestion of iron, commonly prescribed for certain types of anemia, causes discoloration
of the stool (black), nausea, vomiting, constipation (diarrhea is less commonly reported),
and abdominal cramps. The remaining options, although focusing on aspects of function
that could result in constipation, are not focused on the most likely cause in this scenario.
DIF: C
REF: 1190
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
30. Which of the following statements made by a nurse discussing the effect of an antibiotic
on the gastrointestinal system reflects the best understanding of the possible occurrence
of diarrhea?
1. The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and
that causes diarrhea.
2. The antibiotic is responsible for killing off the GI tracts normal bacterial, and
diarrhea is the result.
3. For some, antibiotics irritate the mucous lining of the intestines, causing decreased
absorption and diarrhea.
4. When you are taking an antibiotic, your body is fighting off an infection, and
peristalsis is faster and so diarrhea occurs.
ANS: 2
Antibiotics inadvertently produce diarrhea by disrupting the normal bacterial flora in the
GI tract. The remaining options are not necessarily true.
DIF: A
REF: 1179
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
31. A client is reporting that the oral medication she was prescribed for her hypothyroidism
does not seem to be helping. The client goes on to report that she has been experiencing
tension-related headaches and constipation. She has been self-medicating with
nonsteroidal antiinflammatory drugs (NSAIDs) and bulk laxatives. Which of the
following assessment questions is most likely to provide information regarding this
clients concern regarding her thyroid problem?
1. How long have you taken Synthroid?
2. What other medications are you currently on?
3. How long have you been taking a bulk laxative?
4. Have you developed any other gastrointestinal symptoms?

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Test Bank

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ANS: 3
Laxatives often influence the efficacy of other medications by altering the transit time
(i.e., the time the medication remains in the GI tract and is available for absorption). The
remaining options would have little bearing on the effectiveness of the hypothyroid
medication unless the medication has not been taken long enough to reach therapeutic
levels.
DIF: C
REF: 1178
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
32. The nurse is assessing a cognitively impaired older adult client and observes a leaking of
liquid stool from the rectum. The nurses initial intervention for this client is to:
1. Determine if the client has been eating sufficiently, especially fiber-rich foods
2. Determine how long it has been since the client had a normal-size, formed stool
3. Perform a digital examination of the rectum to determine the presence of stool
4. Call the health care provider to get a prescription for an antidiarrheal medication
ANS: 1
When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion
of feces located higher in the colon seeps around the impacted mass. An obvious sign of
impaction is the inability to pass a stool for several days, despite the repeated urge to
defecate. The digital examination should be performed after it has been determined that
the client has been without a normal bowel movement for several days. Although the
remaining options are not inappropriate, they would not be the initial intervention.
DIF: B
REF: 1179
OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
33. The greatest risk for injury for a client who has fecal incontinence is:
1. Perineal and rectal skin breakdown
2. The contamination of existing wounds
3. Falls resulting from attempts to reach the bathroom
4. Cross-contamination into the upper gastrointestinal tract
ANS: 1
Fecal incontinence is a potentially dangerous condition in terms of contamination and
risk for skin ulceration. The greatest risk to the otherwise healthy individual is skin
breakdown. Although the other options may be risk factors, they are not as great as that of
skin breakdown.
DIF: C
REF: 1181
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and

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Comfort/Elimination
34. The nurse is providing ancillary personnel with instructions regarding the proper methods
to implement when caring for a client with a Clostridium difficile infection. Which of the
following practices will have the greatest impact on containment of the bacteria and thus
prevention of cross-contamination?
1. Frequent in-services on transmission modes of C. difficile
2. Practice of proper hand hygiene by all staff
3. Appropriate handling of contaminated linen
4. Stool cultures on all suspected carriers
ANS: 2
Poor hand hygiene and erratic disinfection practices result in the transmission of C.
difficile. Stool cultures are useful in the diagnosis, not the prevention, of C. difficile.
Although the other options are appropriate, they do not have the most impact on
preventing the spread of these bacteria.
DIF: C
REF: 1180
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Elimination
35. Which of the following clients is at greatest risk for serious complications when using the
Valsalva maneuver to expel feces?
1. 25-year-old pregnant client
2. 66-year-old male with hypertrophied prostate disease
3. 44-year-old male client with glaucoma
4. 53-year-old female with stomach cancer
ANS: 3
Clients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new
surgical wound are at greater risk, such as cardiac irregularities and elevated blood
pressure, with this maneuver and need to avoid straining to pass the stool. Although the
Valsalva maneuver may contribute to hemorrhoids, this is not as serious as increasing the
intraocular pressure of a client with glaucoma. The Valsalva maneuver is not
contraindicated in a client with hypertrophied prostate disease or in a client with stomach
cancer.
DIF: A
REF: 1179
OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
36. The mother of an 18-month-old male client shares with the nurse that she is trying to get
her child to tell her when he needs to have a bowel movement. Which of the following
statements is the most appropriate response from the nurse?
1. "Im sure that you will be glad to have your son out of diapers."

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2. "I once heard of a child who was totally potty-trained by the time he was a year
old."
3. "Development of neuromuscular control of the bowels doesnt normally occur until
a child is between 2 and 3 year of age."
4. "You will have to really be persistent about taking him to the bathroom frequently
in order to be successful."
ANS: 3
Developmental changes affecting elimination occur throughout life. The infant is unable
to control defecation because of a lack of neuromuscular development. This development
usually does not take place until 2 to 3 years of age.
DIF: A
REF: 1177
OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
37. The 35-year-old pregnant client is concerned about constipation. When weighing the
advantages and disadvantages of having a local anesthetic over a general anesthetic for a
caesarian section, the nurse shares with the client that the local will cause less risk for
constipation following surgery. The best reason that there is less constipation following
this surgery is because:
1. The client will not have to be allowed nothing by mouth (NPO) before surgery
2. The client will be able to ambulate immediately following surgery
3. The client will be able to eat following surgery
4. Local or regional anesthetic often has little or no effect on bowel activity
ANS: 4
The client who receives a local or regional anesthetic is less at risk for elimination
alterations because this often affects bowel activity minimally or not at all whereas
general anesthetic agents used during surgery cause temporary cessation of peristalsis,
which can result in constipation. The client will still need to remain NPO before a
scheduled caesarian section in case she would need to receive a general anesthetic. The
client will not be able to ambulate immediately after surgery because of loss of feeling in
the lower extremities. Clients should be able to eat following nonbowel-related surgery
whether or not they have undergone a general anesthetic or a local anesthetic.
DIF: A
REF: 1178
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination

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38. A 44-year-old male client was placed on a daily low-dose aspirin regimen by his health
care provider following a recent diagnosis of hypertension and periodic atrial fibrillation.
The client is currently hospitalized with renal stones. As the nurse is admitting the client,
he shares that he has been very tired. The nurse gathers additional data regarding his
bowel habits. The client shares that he has recently had black, tarry stools. The nurse is
most concerned that the client may have:
1. Colon cancer
2. A GI bleed from the aspirin therapy
3. Ongoing atrial fibrillation
4. Electrolyte imbalance
ANS: 2
Although the client could have any one of the items mentioned, it is most likely that the
aspirin is causing a GI bleed. The loss of blood can cause the client to be fatigued.
Aspirin is a prostaglandin inhibitor, which interferes with the formation and production of
protective mucus and causes GI bleeding.
DIF: C
REF: 1179
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
39. The nurse is counseling a 65-year-old female client on her use of mineral oil as a laxative.
One of the most important things that the nurse can share with the client is how mineral
oil can cause the decreased absorption of which of the following vitamins?
1. Vitamin C
2. Niacin
3. Vitamin D
4. Riboflavin
ANS: 3
Mineral oil, a common laxative, decreases fat-soluble vitamin absorption. Vitamin D is
the only fat soluble vitamin listedthe others are all water-soluble.
DIF: A
REF: 1178
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
40. An active 25-year-old female client shared with the nurse that ever since she had gone on
a high-protein low-carbohydrate diet she had suffered from constipation. The client states
that the diet is working for her in terms of weight loss and would like to stay on it. The
best response from the nurse is that the client should try:
1. Consuming more low-carbohydrate fiber-rich foods like broccoli, raspberries,
blackberries, and asparagus
2. Taking a laxative when feeling constipated
3. Try a different diet with less tendency to cause constipation

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4. Exercise more
ANS: 1
A low-fiber diet high in animal fats (e.g., meats, dairy products, eggs) can slow
peristalsis, leading to constipation. By consuming fiber-rich low-carbohydrate foods, the
client can still maintain weight loss while avoiding constipation. The client could develop
a dependence on laxatives by using them on a regular basis. The client has expressed a
desire to remain on the diet she is currently on, and it seems to be working to help her
lose weight. Because client is already active, additional activity is not likely to have a
profound effect on relieving the constipation.
DIF: A
REF: 1177
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
41. The nurse knows that the client receiving enteral feedings is at risk for diarrhea. One of
the measures that the nurse can take to minimize the risk for diarrhea in this client is:
1. Making sure to chill the canned feeding before administering
2. Using strict sanitation when administering the formula
3. Not deviating from the prescribed rate of delivery for the formula
4. Not diluting or changing the strength of the prescribed formula
ANS: 2
Interventions to prevent diarrhea include the following: administer canned formulas at
room temperature, follow strict sanitation when preparing the formula, increase the rate
slowly, administer the volume at a rate tolerable to your client, or if using a hypertonic
solution, give the initial feeding at half strength and gradually increase the volume to
allow the client to adjust to a hypertonic solution. Consult a dietitian when diarrhea
occurs.
DIF: A
REF: 1180
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
42. Upon auscultation of the clients abdomen, the nurse hears hyperactive bowel sounds
(greater than 35 per minute). The nurse knows that this can indicate which of the
following?
1. Paralytic ileus
2. Fecal impaction
3. Small intestine obstruction
4. Abdominal tumor
ANS: 3

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Absent (no auscultated bowel sounds) or hypoactive sounds (less than five sounds per
minute) occur with paralytic ileus, such as after abdominal surgery. High-pitched and
hyperactive bowel sounds (35 or more sounds per minute) occur with small intestine
obstruction and inflammatory disorders.
DIF: A
REF: 1187
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination
43. The health care provider has ordered a stool specimen for ova and parasites from the 43year-old male client. The nurse knows that when collecting the specimen the stool must
be:
1. Kept on ice
2. Kept warm
3. Collected using sterile technique
4. Free from urine
ANS: 2
It is important to avoid delays in sending specimens to the laboratory. Some tests such as
measurement for ova and parasites require the stool to be warm. The specimen need not
be collected using sterile technique, because the laboratory will not be testing the sample
for bacteria, but it should be collected with good sanitation practices. Likewise, a small
amount of urine should not alter the test results.
DIF: A
REF: 1188
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation Physiological Integrity/Basic Care and
Comfort/Elimination

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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