Bowel elimination

enema used to expel flatus, stimulate peristalsis, and relieve abdominal distention

return-flow/flush

Is an enzyme produced in the mucosal lining of the stomach that acts to degrade protein

Pepsin

Produces and secrets hydrochloric acid, pepsin, intrinsic factor and mucus

Stomach

enema that entails assisting the patient to the toilet or commode or providing bedpan

cleansing

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take. a. warm the enema solution prior to instillation b. prepare 1500 ml of enema fluid c. use tap water as the enema fluid d. hang the enema container 24 inches above the anus

warm the enema solution

A nurse is teaching a client who has constipation about a high fiber diet. Which of the following foods should be included as sources of fiber? a. kidney beans b. blackberries c. refined cereals d. whole wheat bread d. lean turkey

kidney beans, blackberries, whole wheat bread

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? a. prone b. dorsal recumbent c. right lateral with both knees at chest d. left lateral with the right leg flexed

left lateral with the right leg flexed

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. measure the client's vital signs b. notify the PCP c. lower the enema fluid container d. stop the enema instillation

lower the enema fluid container

Is a thick fluid of mass of partially digested food and gastric secretions that is passed from the stomach to the small intestine

Chyme

Where does digestion begin?

Esophagus

The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Lack of knowledge r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

Impaired skin integrity r/t localized skin irritation from liquid stool

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing? a.Keep the patient on a clear liquid diet for 72 hours. b. Send the samples to the laboratory while they are still warm. c. Inform the patient that several stool samples will be needed. d. Use a sterile container when collecting the stool samples.

Inform the patient that several stool samples will be needed.

Is a protein produced by cells in the stomach lining

Intrinsic factor

is the primary organ of bowel elimination

Large intestine

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient's plan of care for the day before the test? a. Provide the patient with zinc oxide skin barrier cream for the perineal area. b. Obtain an order for a gentle laxative to be given once the test is completed. c. Carefully assess the patient's ability to swallow liquids through a straw. d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

Provide the patient with zinc oxide skin barrier cream for the perineal area.

A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include? a. to prevent dehydration, drink an additional liter of fluid during preparation time b. expect bowel movements to begin 3 h following completion of solution c. abdominal bloating might occur d. drink 400 mL every hour until bowel movements are clear

"Abdominal bloating might occur."

A nurse is providing preoperative teaching to a client who in to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? a. "I will be able to eat solid food when I take up from anesthesia b. I will have a glass of juice the morning of my surgery c. I understand what risks I can expect with this surgery d. I will take to relax if I get nervous the night before surgery

"I will be able to eat solid food when I take up from anesthesia

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam? a. "The back of your throat will be sprayed with numbing medicine." b. "You will need to have a clear liquid diet and take a laxative tonight." c. "You will be given a milky liquid to drink shortly before the test starts." d. "You should not take your dose of warfarin (Coumadin) tonight."

"You will be given a milky liquid to drink shortly before the test starts."

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? a. 2.5 cm to 3.75 cm (1 to 1.5 in) b. 5 cm to 7.5 cm (2 to 3 in) c. 7.5 cm to 10 cm (3 to 4 in) d. 10 cm to 12.5 cm (4 to 5 in)

7.5 cm to 10 cm (3 to 4 in)

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient? a. Obtain an order to administer a soap suds cleansing enema. b. Teach the patient how to use the Valsalva maneuver. c. Discontinue medications that can cause constipation. d. Assess the patient's usual pattern of bowel movements.

Assess the patient's usual pattern of bowel movements.

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse? a. Assist the patient to ambulate in the hall. b. Insert a rectal tube to remove retained flatus. c. Administer an enema to stimulate peristalsis. d. Encourage oral intake of fluids and high-fiber foods.

Assist the patient to ambulate in the hall.

The nurse is caring for a patient with a history of dementia who is incontinent of stool because of the inability to communicate the need to defecate. What is the priority action of the nurse? a. Administer a daily laxative and take the patient to the toilet afterward. b. Digitally remove stool from the patient's rectum every other day. c. Insert a rectal tube to facilitate drainage of soft or liquid stool. d. Begin a prompted toileting program to facilitate bowel continence.

Begin a prompted toileting program to facilitate bowel continence.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema. Which of the following nursing actions is appropriate at this time? a. check the clients medical record for the providers prescription b. explain to the client that the provider prescribed the procedure c. assure the client that enemas are commonly prescribed for constipation d. inform the charge nurse that the client refused the enema

Check the client's medical record for the provider's prescription.

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient's new symptoms? a. Clostridium difficile infection b. Paralytic ileus c. Fecal impaction d. Salmonella food poisoning

Clostridium difficile infection

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed? a. Applesauce b. Orange Popsicle c. White toast d. Coffee with cream

Coffee with cream

The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient? a. Lack of knowledge related to prescribed diet modifications b. Impaired nutritional intake related to poor appetite c. Diarrhea related to excessive loss of fluid through stool d. Anxiety related to incontinence with loose stools and need for clothing change

Diarrhea related to excessive loss of fluid through stool

primary function is to transport solids and liquids from the mouth-where digestion begins-into the stomach

Esophagus

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend? a. ginseng b. coenzyme Q-10 c. cranberry juice d. flaxseed

Flaxseed

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema?

History of surgery of the anus and rectum

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Keep the patient NPO and document the findings in the chart. b. Administer a laxative suppository to stimulate peristalsis. c. Insert a Salem sump nasogastric tube to low continuous suction. d. Notify the surgeon and prepare the patient to return to surgery.

Keep the patient NPO and document the findings in the chart.

What's the lying position to administer an enema?

Left side lying sims position

Is a temporary colostomy created in a surgical emergency; it is on the right abdomen

Loop colostomy

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor? a. Water-soluble lubricant is applied to the end of the enema tubing. b. The enema tubing is primed with solution that has been warmed. c. The patient is positioned comfortably in the right side-lying Sims position. d. The patient's bedpan is put at the bedside in preparation for use.

The patient is positioned comfortably in the right side-lying Sims position.

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding b the nurse indicates a need to contact the prescriber and question the order? a.The patient is recovering from a traumatic brain injury. b. The patient has not had a bowel movement for 3 days. c. The patient is to have a lower GI series the following morning. d. The patient had an upper GI series performed the previous day.

The patient is recovering from a traumatic brain injury.

Intrinsic factor is needed for the intestines to efficiently absorb ____

Vitamin B12

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in surgical incision. Which of the following actions should the nurse take? a. place the head of the client's bed in the flat position b. gently reinsert the bowel back into the client's wound c. apply moistened sterile gauze to the site d. position the client on his left side

apply moistened sterile gauze to the site

5 cm to 7.5 cm (2 to 3 in)

appropriate length of insertion for a child

7.5 cm to 10 cm (3 to 4 in)

appropriate length of insertion for adult

2.5 to 3.75 cm (1 to 1.5 in)

appropriate length of insertion for an infant

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, from the stoma that is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have?

ascending colostomy

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? a. the duration of the procedure b. 10 to 15 mins c. until the client feels the urge to defecate d. at least 30 minutes

at least thirty minutes

T/F: The nurse should clamp the client's NG tube during auscultation to prevent mistaking the sound of suction for bowel sounds

true

A nurse is caring for a client who is taking warfarin and has a new prescription for Bactrim to treat a UTI. The nurse should clarify the prescriptions with the provider because taking these 2 drugs concurrently can increase the client's risk for which of the following? a. bleeding b. thrombosis c. ECG changes d. ototoxicity

bleeding

The nurse should auscultate bowel sounds for 3 to 5 minutes prior to making the determination that bowel sounds are absent

true

this position is used for infants and small children during enema administration

dorsal recumbent

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? a. excessive laxative use b. ignoring the urge to defecate c. inadequate fluid intake d. increased fiber in the diet e. increased activity

excessive laxative use, ignoring the urge to defecate, inadequate fluid intake

The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient's bleeding? a. Hemorrhoids b. Bleeding gastric ulcer c. Colon polyps d. Perforated colon

hemorrhoids

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurse's priority?

how long have you been taking the bisacodyl

A nurse is teaching an older client who reports constipation. Which of the following instructions should the nurse include in the teaching? a. bear down hard when defecating b. drink 4 to 5 glasses of water daily c. increase dietary intake of raw veggies d. limit activity

increase dietary intake of raw veggies

order of abdominal assessment

inspection, auscultation, percussion, palpation

A nurse is prioritizing care for 2 clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The 2nd client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? a. weigh the second client b. obtain vital signs for both clients c. administer pain medication to the first client d. change the dressings of both clients

obtain vital signs for both clients

enemas that lubricates the rectum & the colon, making feces softer and easier to pass.

oil-retention

enema entails having the client retain the fluid

retention

T/F: Is soy milk is lactose free?

true

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth b. Assessing the stoma and incision for signs of infection or ischemia c. Obtaining needed supplies from the clean utility room d. Teaching the patient how to care for the ostomy after discharge e. Determining which type of ostomy appliance to use f. Application of skin protectant to the area surrounding the stoma

-Gently cleaning the stoma with warm water and a washcloth -Obtaining needed supplies from the clean utility room -Application of skin protectant to the area surrounding the stoma

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement? a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema

An oil retention enema

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority? a. Provide oral care after each episode of emesis. b. Apply a skin barrier to the patient's perineal area. c. Check the patient for a fecal impaction. d. Administer antiemetic medication with a sip of water.

Check the patient for a fecal impaction.

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient's dinner tray since they are not allowed prior to the test? (Select all that apply.) a. Cherry-flavored gelatin b. Cream of chicken soup c. Glass of apple juice d. Coffee with cream and sugar e. Lemon-flavored Italian ice f. Can of ginger ale

Cherry-flavored gelatin Cream of chicken soup Coffee with cream and sugar

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function? a. Raisin bran with skim milk, fresh fruit, and wheat toast b. Pancakes with maple syrup, bacon, and coffee with cream c. Omelet with cheddar cheese, green pepper, and onions d. Bagel with cream cheese, and strawberry nonfat yogurt

Raisin bran with skim milk, fresh fruit, and wheat toast

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications? a. senna b. motrin c. omeprazole d. zolpidem

Senna

Primary function is to mix food with digestive juices, causing the chemical and mechanical breakdown of food into chyme before entering the small intestine.

Stomach

To prevent constipation in an inactive patient, which early interventions should the nurse implement?

Stool softener administration Increasing the fiber in the diet Increasing physical activity Increasing fluid intake

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon? a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient's nasogastric tube was discontinued the previous day.

The patient has bowel sounds x 4 quadrants and is passing gas.

The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient has skin breakdown from loose stools. b. The patient is constipated with last BM 3 days ago. c. The patient is on a low-fiber, gluten-free diet. d. The patient has painful bleeding hemorrhoids.

The patient is constipated with last BM 3 days ago.

The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis Impaired self-toileting? a. The patient will demonstrate safe transfer technique between wheelchair and toilet. b. The call light will be answered promptly when the patient needs to use the toilet. c. Toileting will be scheduled in the morning when the patient needs to defecate. d. Toilet paper and handwashing items will be kept within easy reach of the patient.

The patient will demonstrate safe transfer technique between wheelchair and toilet.

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient? a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. The patient will have privacy once properly positioned on the toilet.

The patient will remain continent with no perineal skin breakdown.

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. -created in the transverse colon, resulting in 1 or 2 openings -located in the upper abdomen, middle or right side -produce semiformed liquid, malodorous drainage What type of ostomy does the patient have?

Transverse Colostomy

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team?

Wound ostomy continence nurse (WOCN)

A nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching? a. limit drinking milk b. take NSAIDs for pain c. avoid drinking alcohol d. limit strenuous excercise

avoiding drinking alcohol

enema that removes feces when a client is constipated, has a fecal impaction or is undergoing preparation for surgery or diagnostic procedures

cleansing

A nurse is administering a return-flow enema to a client. After instilling 100 ml of enema fluid, which of the following actions should the nurse take? a. instruct the client to retain the fluid b. lower the container to allow the solution to flow back out c. help the client to the toilet or bedside commode d. wait 5 minutes and instill another 100 mL of fluid

lower the container to allow the solution to flow back out

enema used to reduce bacteria in the colon prior to surgery or to exert systematic effect

medicated

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions require interventions by the charge nurse? a. clamps the NG tube during auscultation b. performs auscultation between meals c. auscultates bowel sounds for 3 to 5 minute d. palpates the abdomen prior to performing auscultation

palpates the abdomen prior to performing auscultation

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? a. ulcerative colitis b. cholecystitis c. paralytic ileus d. wound dehiscence

paralytic ileus

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? a. place the client in the dorsal recumbent position on a bedpan b. administer the enema while the client sits on the toilet c. administer an antidiarrheal medication 3 hour prior to the enema d. instill 200 ml of fluid over an hour at 15 min intervals

place the client in the dorsal recumbent position on a bedpan

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? a. after palpating the abdomen b. prior to percussing the abdomen c. after assessing for kidney tenderness d. prior to inspecting the abdomen

prior to percussing the abdomen

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? a. cleansing b. return-flow c. medicated d. oil retention

return flow

enema involves moving 100 to 200 ml of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times

return-flow

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? a. use a sterile swab to obtain the specimen b. place the specimen in a sterile container c. label the paper bag in which specimen container is placed d. send specimen container immediately to the lab

send specimen container immediately to the lab

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

soy milk

A nurse is preparing a teaching plan for a client who has a chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? a. the client should drink 2 to 3 8 ounces of water each day b. the client should follow a high-fiber diet to establish bowel regularity c. the client should try to take in all of the required dietary fibers with the morning meal d. daily bowel movements are not necessary provided the stools are hot hard and dry

the client should follow a high-fiber diet to establish bowel regularity

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a. when the client has the urge to defecate b. every 2 hr while the client is awake c. immediately before the client has a meal d. after the client feels abdominal cramping

when the client has the urge to defecate