A patient with a history of cardiac disease is experiencing constipation. Which of the following laxative types would require the most careful monitoring by the nurse due to its potent and rapid effects on bowel evacuation?
a) Bulk-forming agents
b) Stool softeners
c) Osmotic laxatives
d) Cathartics
Answer: d) Cathartics
Rationale: Cathartics (also known as stimulant laxatives) are the most potent class of laxatives. They work by irritating the intestinal mucosa, which leads to a rapid increase in motility and a powerful evacuation. This can cause significant fluid and electrolyte shifts, cramping, and dehydration. For a patient with cardiac disease, these rapid shifts in fluid and electrolytes can be particularly dangerous, potentially leading to arrhythmias or other cardiac complications. The other options are less potent:
Bulk-forming agents work slowly by absorbing water to soften and increase the size of the stool.
Stool softeners add moisture to the stool to make it easier to pass but do not stimulate the bowel.
Osmotic laxatives draw water into the bowel, which is generally a less aggressive action than cathartics.
A nurse is educating a nursing student about the digestive process. Which of the following statements by the nursing student indicates a correct understanding of chyme?
a) “Chyme is the fully digested food that is absorbed in the large intestine.”
b) “Chyme is a thick, fluid mass of partially digested food and gastric secretions.”
c) “Chyme is the waste product that is stored in the rectum before defecation.”
d) “Chyme is produced in the esophagus to help with the transport of food.”
Answer: b) “Chyme is a thick, fluid mass of partially digested food and gastric secretions.”
Rationale: This statement correctly defines chyme. After food is chewed and swallowed, it enters the stomach, where it is mixed with gastric acids and enzymes. This process breaks the food down into a semi-fluid, acidic mass called chyme. This chyme is then slowly released into the small intestine for further digestion and nutrient absorption. The other options are incorrect:
(a) is incorrect because chyme is only partially digested, and the primary site for nutrient absorption is the small intestine, not the large intestine.
(c) describes feces (or stool), which is the final waste product after the digestive process is complete.
(d) is incorrect because chyme is formed in the stomach, not the esophagus. The esophagus transports the food bolus from the mouth to the stomach.
A 78-year-old client who has been on broad-spectrum antibiotics for a week develops frequent, foul-smelling, watery diarrhea. The nurse recognizes these symptoms as being most characteristic of which of the following conditions?
a) Fecal impaction
b) Hemorrhoids
c) Paralytic ileus
d) Clostridioides difficile infection
Answer: d) Clostridioides difficile infection
Rationale: The key cues are the client’s advanced age, recent antibiotic use, and the onset of foul-smelling, watery diarrhea. Antibiotic therapy disrupts the normal gut flora, allowing an overgrowth of C. difficile, which is a common cause of hospital-acquired diarrhea, especially in older adults.
(a) Fecal impaction would typically present with oozing of liquid stool around a hard mass, not profuse watery diarrhea.
(b) Hemorrhoids are associated with pain and bleeding, not the type of diarrhea described.
(c) A paralytic ileus is the cessation of peristalsis and would result in an absence of bowel movements, not diarrhea.
A nurse is providing pre-procedure instructions to a patient scheduled for a colonoscopy. Which statement by the patient indicates that the teaching has been effective?
a) “I can have a regular breakfast the morning of the procedure.”
b) “It’s okay to drink my red-colored sports drink to stay hydrated.”
c) “I will need to follow a clear liquid diet for 1 to 3 days before the test.”
d) “My partner can wait in the car, as I will be fine to drive myself home.”
Answer: c) “I will need to follow a clear liquid diet for 1 to 3 days before the test.”
Rationale: Proper bowel preparation is critical for visualizing the colon during a colonoscopy. This requires emptying all solid waste from the GI tract, which is achieved by following a clear liquid diet for 1 to 3 days prior to the procedure.
(a) The patient must be NPO (nothing by mouth) for several hours before the procedure to ensure the stomach is empty.
(b) Beverages with red or purple dye are avoided because they can stain the colon lining and be mistaken for blood.
(d) Patients receive sedation for the procedure and are not permitted to drive for at least 12 hours afterward.
A nurse is assessing the stoma of a patient who had a descending colostomy placed two days ago. Which of the following findings would require immediate notification of the surgeon?
a) The stoma is moist and reddish-pink.
b) The stoma is dark purple and dry.
c) A small amount of bleeding is noted during cleaning.
d) The stoma protrudes slightly from the abdominal wall.
Answer: b) The stoma is dark purple and dry.
Rationale: A healthy stoma should be moist and reddish-pink, indicating good blood supply. A dark purple, black, or dry stoma suggests inadequate circulation (necrosis) to the tissue, which is a medical emergency requiring immediate surgical intervention.
(a, c, d) These are all normal findings for a new stoma. It should be moist and pinkish-red, may have minimal bleeding when touched due to its vascularity, and should protrude slightly.
An elderly patient who is on bed rest after a hip fracture complains of not having a bowel movement for four days. The patient’s abdomen is firm and slightly distended. Which nursing action would be most appropriate?
a) Administer a prescribed opioid analgesic for the abdominal discomfort.
b) Encourage the patient to consume a diet high in cheese and lean meats.
c) Obtain an order from the provider for a stool softener and increase fluid intake.
d) Inform the patient that this is a normal occurrence with decreased activity.
Answer: c) Obtain an order from the provider for a stool softener and increase fluid intake.
Rationale: The patient is at high risk for constipation due to immobility and potential use of opioid analgesics for pain. Constipation is characterized by infrequent bowel movements (fewer than three per week) and hard, dry stools. The most appropriate initial action is to implement measures that soften the stool and promote peristalsis, such as increasing fluids and using a stool softener.
(a) is incorrect because opioid analgesics are a common cause of constipation by slowing GI motility.
(b) is incorrect because cheese and lean meats are low-fiber foods that can contribute to constipation.
(d) is incorrect because while constipation is common in this situation, it is not a “normal occurrence” that should be ignored; it requires intervention to prevent complications like fecal impaction.
Of course. Here are more NCLEX-style questions and answers based on the highlighted terms from page 1022 of your book.
Constipation
An elderly patient who is on bed rest after a hip fracture complains of not having a bowel movement for four days. The patient’s abdomen is firm and slightly distended. Which nursing action would be most appropriate?
a) Administer a prescribed opioid analgesic for the abdominal discomfort.
b) Encourage the patient to consume a diet high in cheese and lean meats.
c) Obtain an order from the provider for a stool softener and increase fluid intake.
d) Inform the patient that this is a normal occurrence with decreased activity.
Answer: c) Obtain an order from the provider for a stool softener and increase fluid intake.
Rationale: The patient is at high risk for constipation due to immobility and potential use of opioid analgesics for pain. Constipation is characterized by infrequent bowel movements (fewer than three per week) and hard, dry stools. The most appropriate initial action is to implement measures that soften the stool and promote peristalsis, such as increasing fluids and using a stool softener.
(a) is incorrect because opioid analgesics are a common cause of constipation by slowing GI motility.
(b) is incorrect because cheese and lean meats are low-fiber foods that can contribute to constipation.
(d) is incorrect because while constipation is common in this situation, it is not a “normal occurrence” that should be ignored; it requires intervention to prevent complications like fecal impaction.
Defecation
A nurse is teaching a group of students about the process of bowel elimination. The nurse determines that the teaching has been effective when a student identifies which event as the primary stimulus for the defecation reflex?
a) The entry of chyme into the duodenum.
b) The stretching of the rectal wall as feces enters the rectum.
c) The mixing of food with gastric juices in the stomach.
d) The absorption of water and electrolytes in the colon.
Answer: b) The stretching of the rectal wall as feces enters the rectum.
Rationale: The process of defecation begins when peristaltic waves move feces into the rectum. This causes the rectal walls to stretch, which stimulates nerve receptors. These receptors then transmit signals to the spinal cord, creating the conscious urge to defecate and causing the internal anal sphincter to relax.
(a) relates to the initial stages of digestion in the small intestine.
(c) describes the function of the stomach in creating chyme.
(d) describes the primary function of the colon but is not the direct trigger for the defecation urge.
A patient is admitted to the medical-surgical unit with severe diarrhea that has lasted for 3 days. Which of the following is the priority for the nurse to monitor?
a) Skin integrity of the perianal area.
b) The patient’s body image and self-esteem.
c) The patient’s fluid and electrolyte balance.
d) The frequency and characteristics of the stools.
Answer: c) The patient’s fluid and electrolyte balance.
Rationale: Diarrhea is the frequent passage of loose, watery stools. This condition can quickly lead to significant losses of fluid and electrolytes (especially potassium and sodium), resulting in dehydration, hypotension, and potentially life-threatening cardiac dysrhythmias. Therefore, monitoring and maintaining fluid and electrolyte balance is the highest priority.
(a) and (d) are important assessments, but they are not as immediately life-threatening as a severe fluid and electrolyte imbalance.
(b) is a valid psychosocial concern, but physiological stability is the priority according to Maslow’s hierarchy of needs.
A nurse is preparing to administer a cleansing enema to a patient. Which action is essential for the nurse to perform to ensure patient safety and comfort?
a) Administer the solution as quickly as possible to ensure effectiveness.
b) Position the patient in the left side-lying (Sims’) position with the right knee flexed.
c) Heat the enema solution in the microwave to a temperature of 115° F (46° C).
d) Insert the rectal tube 6 to 8 inches into the rectum to bypass the internal sphincter.
Answer: b) Position the patient in the left side-lying (Sims’) position with the right knee flexed.
Rationale: The left Sims’ position is the correct and safest position for administering an enema. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving the effectiveness of the procedure and limiting patient discomfort.
(a) is incorrect. Administering the solution too quickly can cause severe cramping, distention, and damage to the intestinal mucosa. The solution should be instilled slowly over 5 to 10 minutes.
(c) is incorrect. The solution should be warmed to slightly above body temperature (around 100° to 105° F or 37.8° to 40.5° C). Water that is too hot can burn the intestinal lining, while cold water can cause cramping.
(d) is incorrect. The standard insertion depth for an adult is 3 to 4 inches (7.5 to 10 cm). Inserting the tube further risks perforating the bowel wall.
A nurse is providing instructions to a patient who needs to collect stool samples for a fecal occult blood test (FOBT). Which statement by the patient indicates a need for further teaching?
a) “I will collect three separate stool samples on three different days.”
b) “I will be sure to eat a large steak the night before I collect my first sample.”
c) “I should avoid taking my daily vitamin C supplement for a few days before the test.”
d) “I will use the wooden applicator to smear a thin layer of stool onto the test card.”
Answer: b) “I will be sure to eat a large steak the night before I collect my first sample.”
Rationale: The patient should avoid consuming red meat for up to 72 hours before a guaiac-based fecal occult blood test (gFOBT) because the hemoglobin in the meat can cause a false-positive result.
(a) is correct because colon cancers may bleed intermittently, so collecting three separate samples increases the chance of detection.
(c) is correct as high doses of vitamin C can interfere with the chemical reaction and cause a false-negative result.
(d) describes the correct procedure for preparing the sample card.
A postoperative patient who has not yet had a bowel movement complains of severe, sharp abdominal pain and cramping. The abdomen is distended, and the nurse auscultates high-pitched, rushing bowel sounds. Which condition does the nurse suspect?
a) Fecal impaction
b) Paralytic ileus
c) Diarrhea
d) Excessive flatulence
Answer: d) Excessive flatulence
Rationale: After surgery, especially abdominal surgery, peristalsis can be sluggish, allowing gas to accumulate in the intestine. This buildup of flatus (gas) can cause significant abdominal distention and sharp, cramping pain.
(a) Fecal impaction is less likely in the immediate postoperative period before the patient has resumed a normal diet.
(b) A paralytic ileus is characterized by the absence of bowel sounds, not hyperactive ones.
(c) Diarrhea would involve the passage of liquid stool, which is not mentioned in the scenario.
A patient complains of pain and bright red blood on the toilet paper after having a bowel movement. The patient states, “It hurts when I try to pass stool, so I try to hold it in.” The nurse understands that this patient’s condition is most consistent with:
a) A colostomy
b) A fecal impaction
c) Hemorrhoids
d) Clostridioides difficile
Answer: c) Hemorrhoids
Rationale: Hemorrhoids are swollen and inflamed veins in the rectum and anus. The classic symptoms include pain during defecation and the presence of bright red blood on the stool or toilet paper. The pain often leads to a fear of defecation, which can cause patients to ignore the urge, leading to constipation.
(a) A colostomy is a surgical opening and would not cause this specific presentation.
(b) A fecal impaction might cause pain but is more often associated with the oozing of liquid stool.
(d) C. difficile infection is characterized by profuse, watery, foul-smelling diarrhea.
A nurse is developing a plan of care for a patient who has a new ileostomy. Which intervention is the priority for this patient?
a) Teaching the patient how to regulate the frequency of stool.
b) Monitoring for fluid and electrolyte imbalances.
c) Applying a barrier cream to the stoma before pouching.
d) Irrigating the ostomy to promote regular bowel movements.
Answer: b) Monitoring for fluid and electrolyte imbalances.
Rationale: An ileostomy bypasses the entire large intestine, which is the primary site for water absorption. As a result, the stool (effluent) is liquid and continuous, leading to a high risk for dehydration and significant electrolyte loss, particularly sodium and potassium. Therefore, monitoring for signs of fluid and electrolyte imbalance is the highest physiological priority.
(a) is incorrect because stool from an ileostomy is liquid and cannot be regulated.
(c) is incorrect. Barrier creams are generally not used directly on the stoma; a properly fitting skin barrier (wafer) is the primary method for protecting the peristomal skin.
(d) is incorrect because ileostomies are not irrigated in the same way some colostomies are to regulate bowel movements.
An 80-year-old, bed-bound patient reports the inability to have a bowel movement for several days but is now experiencing the continuous oozing of a small amount of liquid stool. The nurse recognizes this as the cardinal sign of which condition?
a) Diarrhea
b) Paralytic ileus
c) Fecal impaction
d) Bowel incontinence
Answer: c) Fecal impaction
Rationale: The classic sign of fecal impaction is the leakage or oozing of liquid stool around a hard, obstructing mass of feces in the rectum. The patient often feels the urge to defecate but cannot pass the hardened stool. The liquid portion of the feces from higher in the colon seeps around the obstruction.
(a) Diarrhea would involve the passage of large amounts of liquid stool, not just oozing.
(b) A paralytic ileus is the absence of peristalsis and would result in no stool or bowel sounds.
(d) While the patient is incontinent of the liquid stool, the underlying cause described is the impaction.
A nurse is caring for an alert and oriented patient who is experiencing fecal incontinence due to nerve damage. Which nursing diagnosis should the nurse prioritize to address the patient’s emotional well-being?
a) Impaired Skin Integrity
b) Fluid Imbalance
c) Disturbed Body Image
d) Impaired Self-Toileting
Answer: c) Disturbed Body Image
Rationale: Incontinence, the inability to control fecal discharges, can be profoundly distressing and embarrassing for an alert patient. It can lead to feelings of shame, social isolation, and a negative perception of oneself. Therefore, addressing the patient’s Disturbed Body Image is a crucial psychosocial priority.
(a), (b), and (d) are all valid potential diagnoses, but they address the physiological and functional consequences of incontinence. Disturbed Body Image directly addresses the patient’s emotional response and self-perception, which is a key aspect of holistic care in this situation.
A patient is admitted to the emergency department after ingesting a toxic substance. The provider orders gastric lavage. The nurse prepares for this procedure, understanding that its primary purpose is to:
a) Administer medication directly into the stomach.
b) Provide enteral nutrition to an unconscious patient.
c) Irrigate the stomach to remove the ingested poison.
d) Decompress the stomach by removing excess gas.
Answer: c) Irrigate the stomach to remove the ingested poison.
Rationale: Gastric lavage is the irrigation or washing out of the stomach. It is performed in specific emergency situations, such as active bleeding or, as in this case, poisoning, to remove toxic substances before they are absorbed into the bloodstream.
(a) describes medication administration, which is not the purpose of lavage.
(b) describes the purpose of a feeding tube for enteral nutrition.
(d) describes gastric decompression, which is typically done with a Salem sump tube connected to suction, not lavage.
A nurse is teaching an older adult about the use of over-the-counter laxatives for occasional constipation. Which statement by the patient indicates a correct understanding of the teaching?
a) “I should use a strong laxative daily to ensure I have a bowel movement.”
b) “Laxatives are milder than cathartics and are used to produce a soft stool.”
c) “If I feel nauseated or have abdominal pain, a laxative will help.”
d) “All laxatives work by irritating the lining of my intestine.”
Answer: b) “Laxatives are milder than cathartics and are used to produce a soft stool.”
Rationale: Laxatives are medications that have a milder action than cathartics and are intended to ease defecation by producing soft or liquid stools. The term is often used interchangeably with cathartics, but cathartics have a stronger, more rapid effect.
(a) Chronic use of laxatives can lead to dependency and rebound constipation.
(c) Laxatives are contraindicated in patients with nausea, vomiting, or undiagnosed abdominal pain, as these could be signs of a bowel obstruction.
(d) This describes the mechanism of only one type of laxative (stimulants). Other types, like bulk-forming agents and stool softeners, work differently.
A patient is scheduled for a procedure that will result in a permanent ostomy. The nurse is explaining the basic concept of the procedure. Which statement is the most accurate description of an ostomy?
a) “It’s a temporary opening used only to instill medication into the bowel.”
b) “It is a test that uses a scope to visualize the inside of your colon.”
c) “It is a surgically created opening that exits onto the skin to drain waste.”
d) “It’s a specific type of enema used to cleanse the bowel before surgery.”
Answer: c) “It is a surgically created opening that exits onto the skin to drain waste.”
Rationale: An ostomy is a general term for a surgically created opening in a gastrointestinal, urinary, or respiratory organ that is exited onto the skin to divert waste or bodily fluids.
(a) is incorrect because ostomies can be permanent and are for draining waste, not primarily for instilling medication.
(b) describes a colonoscopy.
(d) describes an enema.
A nurse is assessing a patient on the second postoperative day following abdominal surgery. The nurse auscultates the patient’s abdomen and notes a complete absence of bowel sounds. The patient also reports bloating and has not passed any flatus. The nurse suspects which condition?
a) Clostridioides difficile infection
b) Fecal impaction
c) Paralytic ileus
d) Diarrhea
Answer: c) Paralytic ileus
Rationale: A paralytic ileus is the cessation of peristalsis, often occurring after abdominal surgery due to the effects of anesthesia and manipulation of the bowel. The hallmark signs are the absence of bowel sounds, abdominal distention, and the inability to pass flatus or stool.
(a) and (d) are incorrect because a C. difficile infection would cause hyperactive bowel sounds and profuse diarrhea.
(b) Fecal impaction would likely present with hypoactive bowel sounds and oozing of liquid stool.
A nurse is explaining the digestive process to a patient. Which statement best describes the function of peristalsis?
a) “It is the chemical breakdown of food by stomach acid.”
b) “It is the absorption of nutrients through the intestinal wall.”
c) “It is the progressive wavelike contraction and relaxation of the intestine walls.”
d) “It is the act of voluntarily contracting the abdominal muscles to defecate.”
Answer: c) “It is the progressive wavelike contraction and relaxation of the intestine walls.”
Rationale: Peristalsis is the involuntary, progressive, wavelike muscular movement that propels chyme and, eventually, feces through the gastrointestinal tract.
(a) describes chemical digestion in the stomach.
(b) describes absorption, which occurs primarily in the small intestine.
(d) describes part of the act of defecation, which is under some voluntary control.
During a routine colonoscopy, a 55-year-old patient has several polyps removed. The patient asks the nurse what a polyp is. Which is the nurse’s best response?
a) “They are swollen and inflamed veins in the rectum that can cause bleeding.”
b) “They are a type of bacterial infection that causes severe diarrhea.”
c) “They are small, abnormal growths in the colon that can sometimes become cancerous.”
d) “They are hard masses of stool that get stuck in the colon.”
Answer: c) “They are small, abnormal growths in the colon that can sometimes become cancerous.”
Rationale: Polyps are abnormal growths of tissue found in the colon. While often benign, they are removed during a colonoscopy because they are a known precursor to colorectal cancer. Screening tests like colonoscopies are performed to find and remove polyps early.
(a) describes hemorrhoids.
(b) describes an infection like C. difficile.
(d) describes a fecal impaction.
When assessing a patient’s newly created stoma, which finding would indicate to the nurse that the stoma has a healthy and adequate blood supply?
a) The stoma is a deep, purplish color and is dry to the touch.
b) The stoma is pale pink and retracted below the skin level.
c) The stoma is dark pink to red in color and feels moist.
d) The stoma is flush with the skin and has a gray appearance.
Answer: c) The stoma is dark pink to red in color and feels moist.
Rationale: A healthy stoma should be dark pink to red, similar to the color of the mucosal lining of the mouth, and should be moist. This coloration indicates good circulation.
(a) and (d) A purple, black, or gray stoma indicates necrosis or a compromised blood supply, which is a medical emergency. A dry stoma is also an abnormal finding.
(b) A pale pink stoma can indicate anemia, and a retracted stoma can cause leakage and skin issues.
A nurse is preparing to administer a rectal suppository to a patient for constipation. To ensure the medication is effective, what is the most important action for the nurse to take?
a) Insert the suppository just inside the internal anal sphincter.
b) Place the suppository against the rectal mucosa.
c) Break the suppository into two pieces for easier insertion.
d) Instruct the patient to have a bowel movement immediately after insertion.
Answer: b) Place the suppository against the rectal mucosa.
Rationale: For a suppository to be absorbed and have its intended effect (either local or systemic), it must be placed in contact with the mucosal lining of the rectum. Placing it within a fecal mass will prevent it from dissolving and being absorbed properly.
(a) The suppository should be inserted past the internal sphincter (approximately 4 inches for an adult).
(c) A suppository should never be broken; it is designed to be administered whole.
(d) The patient should be instructed to retain the suppository for as long as possible (usually at least 30 minutes for a laxative effect) to allow it to work.
A nurse is teaching a patient with pernicious anemia about the digestive system. The nurse explains that the stomach produces a substance essential for the absorption of vitamin B12. Which substance is the nurse referring to?
a) Pepsin
b) Chyme
c) Hydrochloric acid
d) Intrinsic factor
Answer: d) Intrinsic factor
Rationale: The text states, “Intrinsic factor is a protein produced by cells in the stomach lining. It is needed for the intestines to efficiently absorb vitamin B12.” Pepsin degrades protein, hydrochloric acid breaks down food structures, and chyme is the partially digested food mass.
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