GI Assessment & Bowel Elimination
What is the correct order for performing an abdominal assessment?
Inspect, auscultate, percuss, palpate (IAPP).
What type of ostomy diverts stool from the small intestine?
Ileostomy
What is the minimum hourly urinary output commonly used as a nursing assessment guideline for adults?
Approximately 30 mL/hour
What bacteria most commonly cause uncomplicated urinary tract infections?
E. Coli
What medication class increases stool bulk by absorbing water in the intestines?
Bulk-forming laxatives
What is the medical term for black, tarry stools that may indicate gastrointestinal bleeding?
Melena
What color should a healthy stoma normally appear?
Red
What type of urinary catheter is commonly used for continuous bladder irrigation?
Three-way Foley catheter.
A patient has frequent small-volume urination, lower abdominal discomfort, and a post-void residual of 650 mL. What condition should the nurse suspect, and what is the priority concern?
Urinary retention. The priority is evaluating bladder overdistention and the need for prompt bladder drainage according to provider orders or protocol.
What common over-the-counter medication is used to decrease intestinal motility and treat certain types of diarrhea?
Loperamide (Imodium).
A patient has not had a bowel movement in three days. What should the nurse assess before administering a laxative?
Bowel sounds, abdominal distention, pain, normal bowel habits, and ability to pass gas.
A newly created stoma appears dark purple or black. What complication should the nurse suspect?
Impaired blood supply, potentially causing ischemia or tissue necrosis.
What is the primary purpose of maintaining a closed urinary catheter drainage system?
To reduce the risk of introducing bacteria and developing a catheter-associated urinary tract infection (CAUTI).
A patient reports fever, chills, flank pain, and tenderness at the costovertebral angle. What urinary condition should the nurse suspect?
Pyelonephritis (kidney infection).
A patient with diarrhea has dry mucous membranes, dizziness, and decreased urinary output. What complication should the nurse suspect?
Fluid volume deficit (dehydration).
A patient experiences liquid stool leakage but reports being constipated for several days. What condition should the nurse suspect?
Fecal impaction
What is a major complication associated with repeated large-volume enemas?
Fluid and electrolyte imbalances
A Foley catheter was removed six hours ago. The patient has not urinated and reports lower abdominal pressure. What should the nurse assess?
Bladder distention and possible urinary retention, including a bladder scan when indicated.
An older adult with arthritis cannot reach the bathroom quickly enough and experiences urinary accidents. What type of incontinence is this?
Functional incontinence.
A patient with chronic constipation takes opioids for postoperative pain. The patient has abdominal distention, vomiting, and has not passed gas. Why would administering psyllium be inappropriate before further assessment?
The symptoms may indicate ileus or bowel obstruction. Bulk-forming laxatives could worsen the condition and should not be administered until obstruction has been evaluated.
After a barium radiograph, what nursing interventions help prevent constipation and impaction?
Encourage fluids if permitted, administer a prescribed laxative if ordered, and monitor bowel movements.
A patient has severe abdominal pain, vomiting, distention, and suspected bowel obstruction. Why should the nurse avoid administering a cleansing enema without further evaluation?
An enema could worsen the condition or increase the risk of bowel injury or perforation.
A patient with an indwelling catheter develops fever, suprapubic tenderness, and cloudy urine. What complication should the nurse suspect?
Catheter-associated urinary tract infection (CAUTI).
What is the medical term for painful or burning urination?
Dysuria
Why should bulk-forming laxatives generally be avoided in patients with suspected bowel obstruction?
Increasing stool bulk may worsen the obstruction.