Online Practice Test 49

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 49 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 1:40 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		The nurse is presenting information at the community health fair about normal defecation patterns across the lifespan. Which of the following factors would not be part of the discussion? Your Answer: Gender
		Objective: Understand the physiology of defecation. Rationale: There is no relationship noted between gender and defecation pattern. Diet, fluids, and medications all can affect amount, consistency, or pattern of defecation. Nursing Process: Implementation Client Need: Health Promotion and Maintenance and Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The elderly population is known to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would identify all of the following except: (Select all that apply.)  Your Answer: Laxatives increase the absorption of certain vitamins. Correct Answers: Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. Habitual use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced. Laxatives may interfere with fluid and electrolyte balance.
		Objective: Identify measures that maintain normal fecal elimination patterns. Rationale: Laxatives decrease the absorption of vitamins. The remaining answer choices are true. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		The nurse encounters a 75-year-old in the emergency department, with complaints of nausea, diarrhea, and anorexia. He has been evaluated, and it is determined that he can be treated at home. In discussing the guidelines of managing diarrhea, the nurse knows the client understands his care measures when he says:  Your Answer: "I will eat fried chicken for supper." Correct Answer: "I will increase foods with fiber, like oatmeal."
		Objective: Identify factors that influence fecal elimination and patterns of defecation. Rationale: Increasing roughage (fiber) in the diet helps to add bulk to the stool. Eight glasses of water remains the recommended fluid recommendation, although there is some disagreement. Beverages with caffeine, like tea, and fatty foods like fried chicken aggravate diarrhea. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and process of elimination.
4.		A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon. The type of stool that the client can expect from this stoma is: Your Answer: Increasingly solid
		Objective: Describe essentials of fecal stoma care for clients with an ostomy. Rationale: Stool in the descending colon is often formed, and the tissue can be trained for periodic defecation. Liquid stool and malodorous stool that cannot be controlled is found within the ascending colon. Malodorous, mushy stool is noted in the transverse colon. Output is always expected at some point in time from ostomies as evidence of their functioning. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: Your Answer: Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection
		Objective: Describe essentials of fecal stoma care for clients with an ostomy. Rationale: Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Read question and prioritize nursing actions.
6.		At the local wellness fair, the nurse is asked to share information on having healthy bowel life. Included in this area is the topic of having a healthy defecation. The nurse should include which of the following information as appropriate action to follow? Your Answer: Establishing a regular exercise regimen
		Objective: Identify factors that influence fecal elimination and patterns of defecation. Rationale: Exercise helps to stimulate muscle functioning and metabolic activity, thus promoting healthy defecation. High-fiber foods are encouraged in the diet of this client. Do not avoid the urge to defecate, because this conditioned reflex tends to weaken or is ultimately lost. Six to eight glasses of water are recommended to maintain fluid balance in the body. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		An 80-year-old client is in the emergency department. The client complains of diarrhea and vomiting for the past two days. In assessing the client, it is noted that his skin is dry and can be tented, he has lost eight pounds, and is itchy. Which NANDA diagnosis would be most appropriate to use with this client in making his plan of care?  Your Answer: Risk for Deficient fluid volume related to prolonged diarrhea and vomiting
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. Rationale: This client is showing signs of dehydration. The first answer is the only appropriate answer. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
8.		When using a rectal tube in helping a client expel flatulence, the most appropriate intervention to be followed by the nurse is Your Answer: Encourage the client to assume various positions in bed once the tube is inserted.
		Objective: Identify measures that maintain normal fecal elimination patterns. Rationale: Varying the position from side-lying to sitting to supine helps the client to expel flatus. The side-lying position is recommended for use during insertion. Lubrication of the tube helps to ease the insertion process and prevent damage to the tissue. The tube should not be left in the client for more than 30 minutes, to avoid irritation to the rectal mucosa. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A client has had a stroke, and can no longer move her bowels on her own accord. A bladder-training program is to be established for her. Before beginning this program, the client and her family members must understand what is involved with this care. Which of the following would be the most appropriate directions or information to share? Your Answer: Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. Rationale: The best results can be obtained by inserting the suppository 30 minutes before the client's usual defecation time, or when the peristaltic action is greatest. The daily routine in bowel training is recommended to be 2-3 weeks. When the client experiences the urge to defecate, assist the client to the toilet/commode/bedpan to defecate. Fluid intake, increased fiber in the diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defecation on a regular basis. Nursing Process: Analysis Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions.
10.		The nurse has completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments? (Select all that apply.) Your Answer: Type of solution Length of time solution retained Amount of return Correct Answers: Type of solution Length of time solution retained Relief of flatus and abdominal distention
		Objective: Describe the purpose and action of commonly used enema solutions. Rationale: Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions. Objective: Describe the purpose and action of commonly used enema solutions. Rationale: Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions.