Bowel Elimination Chapter 38 PrepU N400

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? "Auscultated abdomen for bowel sounds. Bowel not functioning." "All four abdominal quadrants auscultated. Inaudible bowel sounds." "Bowel sounds auscultated. Client has no bowel sounds." "Client may have bowel sounds, but they can't be heard."

"All four abdominal quadrants auscultated. Inaudible bowel sounds." Explanation: In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply. "How often do you go out to eat?" "Do you use anything to help move your bowels?" "How often do you move your bowels?" "Where do you do your grocery shopping?" "Do you prefer hot foods or cold foods?"

"Do you use anything to help move your bowels?" "How often do you move your bowels?" Explanation: To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply. "Have you started a new medication?" "What are your normal bowel habits?" "Are you experiencing rectal fullness?" "Do you use laxatives?" "Is the stool difficult to pass?"

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?" Explanation: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

The nurse has completed client teaching about draining a continent ileostomy. Which client statement(s) requires further teaching by the nurse? Select all that apply. "I should never strain as if having a bowel movement." "I will stop advancing the tube if I encounter resistance." "It will take 15 to 20 minutes for complete emptying." "The catheter should be cleaned with warm, soapy water." "The external end of the catheter should be placed at least 12 in (30 cm) below the stoma."

"I should never strain as if having a bowel movement." "I will stop advancing the tube if I encounter resistance." "It will take 15 to 20 minutes for complete emptying." Explanation: Further teaching is needed to clarify that bearing down (as if having a bowel movement) can assist with drainage, it will take 5 to 10 minutes for complete emptying, and that resistance is expected at approximately 2 in (5 cm) into insertion. Teaching has been effective when the client understands that the catheter should be cleaned with warm, soapy water, and that the external end of the catheter should be placed at least 12 in (30 cm) below the stoma.

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct? "I will administer up to three enemas as prescribed." "I will administer enemas until the enema return is without stool." "You will need to have enemas unless you can consume clear liquids without nausea." "This enema will assist in your bowel regimen when you go home."

"I will administer enemas until the enema return is without stool." Explanation: "Enemas until clear" means that the nurse would administer enemas until no more stool is noted on output. A nurse would not be able to determine if the entire intestinal tract is clear. Administering three enemas is not what the prescriber ordered. Consuming clear liquids does not impact the use of enemas. The enema may not be part of the client's discharge instructions.

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate? "Irrigating the colostomy can help establish an elimination routine." "It is impossible to anticipate when a bowel movement will occur." "Increasing fiber in your diet will help promote regular bowel movements." "Once you recover from surgery, your bowel elimination pattern will become regular."

"Irrigating the colostomy can help establish an elimination routine." Explanation: Irrigations are used to promote regular evacuation of some colostomies. Left-sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response? "This is good to help bowels move." "Perhaps you should do this twice daily." "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." "It is important that you discontinue this type of treatment immediately."

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins." Explanation: The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation.

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse? "Stool cannot be collect from a child's diaper." "Stool can be collected only from a cloth diaper." "It depends on which testing developer is used." "Only if the stool has not been contaminated by urine."

"Only if the stool has not been contaminated by urine." Explanation: Stool can be collected from a diaper for occult blood testing only if the stool has not been contaminated by urine. It does not matter whether the diaper is disposable or cloth. The type of developer does not make a difference as all are used to test for occult blood.

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? "This will determine what foods you are allergic to that affect digestion and elimination." "This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." "This test detects heme, an iron compound in blood within the stool." "This test will help determine whether you have an infectious process in the intestines."

"This test detects heme, an iron compound in blood within the stool." Explanation: The nurse will teach that the FOBT detects heme. It does not test for allergic foods, nor does it test for infection. The fecal immunochemical test (FIT) test results have a high rate of specificity for colorectal cancer.

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? "This test will determine whether foods are contributing to rectal bleeding." "This test will show if you have colorectal cancer." "This test will show if you have an infection in the bowel." "This test detects heme, a type of iron compound in blood in the stool."

"This test detects heme, a type of iron compound in blood in the stool." Explanation: The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? 3 in (7.5 cm) 1 in (2.5 cm) 2 in (5.0 cm) 5 in (12.5 cm)

3 in (7.5 cm) Explanation: The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? 33-year-old client who reports painful elimination 42-year-old client with diarrhea twice weekly 50-year-old client with a family history of polyps 67-year-old client with constipation

50-year-old client with a family history of polyps Explanation: The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action? A risk that the peristomal skin will become excoriated The appliance will need to be changed daily. The appliance will fit securely to the client's skin. A heightened risk that the stoma will prolapse

A risk that the peristomal skin will become excoriated Explanation: An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client? Assess the color of the stoma. Apply device for stool collection. Perform stoma irrigation. Have the client perform self stoma care

Assess the color of the stoma. Explanation: A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? Take 500 mg Consume citrus fruits Drink orange and grapefruit juice Avoid more than 250 mg

Avoid more than 250 mg Explanation: The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action? Discontinue the administration of the enema Remove the tubing. Continue infusing at a faster rate to finish the enema quicker. Clamp the tube for a brief period and resume at a slower rate.

Clamp the tube for a brief period and resume at a slower rate. Explanation: Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? Collect 15 to 30 mL of the client's liquid stool. If portions of the stool include visible blood, mucus, or pus, discard the stool. If the specimen contains barium or enema solution, document this on the container. Refrigerate the specimen until it is cooled before sending it to the laboratory.

Collect 15 to 30 mL of the client's liquid stool. Explanation: Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately.

A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply. Ordering the test Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test Planning medical treatment based on test results

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test Explanation: The nurse should follow facility protocol to collect, handle, and transport a specimen. It is very important to adhere to protocols and standards, collect the appropriate amount, use appropriate containers and media, and store and transfer the specimen within specified timelines. Client teaching is also an important part of specimen collection. The primary health care provider orders the test and plans medical treatment based on the results.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? Digital removal of stool may cause parasympathetic stimulation. Nurses find the procedure distasteful and difficult to perform. Most clients will not consent to have digital removal of stool. It often causes rebound diarrhea and electrolyte loss.

Digital removal of stool may cause parasympathetic stimulation. Explanation: The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do? Document the output; this is normal. Contact the physician immediately. Give the client the ordered laxative. Assess for obstruction.

Document the output; this is normal. Explanation: Output from a colostomy is normally formed stool. Therefore the nurse should document the output as normal. There is no need to contact the physician at this time, assess for an obstruction, or give a laxative since the formed stool is normal.

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. Help the client into a Sims' position. Cool the container holding the solution. Compress the container as the solution instills. Wipe the lubricated tip of the container before insertion. Encourage the client to retain the solution.

Encourage the client to retain the solution. Explanation: When administering a hypertonic enema solution to a client, the nurse should assist the client in a Sims' position because this position promotes gravity distribution of the solution. Compressing the container as the solution instills provides positive pressure, rather than gravity, to instill fluid. Encouraging the client to retain the solution for 5 to 15 minutes promotes effectiveness. The nurse should warm, not cool, the container containing the solution for client comfort. The nurse should apply additional lubricant, not wipe the lubricated tip of the container, before insertion.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube? Every 8 to 10 hours Every 1 to 2 hours Nasogastric tubes should not be irrigated. Every 4 to 8 hours

Every 4 to 8 hours Explanation: The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces. True False

False Explanation: A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.

Which statement about ostomy irrigation is true? For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Daily irrigation is necessary to assure passage of stool from an ileostomy. Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery.

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Explanation: For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance. Daily irrigation is necessary to assure passage of stool from an ileostomy is not warranted as ileostomy do not require daily irrigation. A contract is not necessary to sign to use the equipment. Ostomy prolapse can be delayed by resting until the prolapse recedes and twice daily irrigation is not necessary.

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure? Position the client supine, as dictated by client comfort and condition. Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client not to bear down while extracting feces in order to prevent vagal response.

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Explanation: For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal.

A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding? Put on sterile gloves and gently reposition the stoma. Promptly notify the client's primary care provider. Irrigate the client's colostomy. Have the client rest for half an hour and then reassess.

Have the client rest for half an hour and then reassess. Explanation: If the stoma is prolapsed, the nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to it. Irrigation and manipulation are not recommended responses to this situation.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? Visible waves of abdominal peristalsis Hyperactive bowel sounds Increased anal area pigmentation Dry, hard stool

Hyperactive bowel sounds Explanation: Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.

Which principle should guide the nurse's collection of a fecal occult blood test? The nurse must assess the client's food and medication intake for the 2 weeks prior to the test. If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Recent use of over-the-counter stool softeners can cause a false-positive result. The results of the test will preliminarily indicate the site of a client's bleeding.

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Explanation: In a woman who is menstruating, the test should be postponed until 3 days after her period has ended. Before stool testing, the client should avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results; there is no need to assess for a 2-week window. Stool softeners do not confound the results of testing. Results indicate the presence of blood, but not its source.

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order. Percussion Inspection Palpation Auscultation

Inspection Auscultation Percussion Palpation Explanation: When assessing a client's abdomen, the correct order for assessment is inspection, auscultation, percussion, and palpation.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? Right lateral Left lateral Prone Semi-Fowler's

Left lateral Explanation: The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? Remove the tubing and discontinue the procedure. Lower the solution container and check the temperature and flow rate. Place the client on a bedpan in the supine position while receiving the enema. Reposition the rectal tube and check for any fecal content.

Lower the solution container and check the temperature and flow rate. Explanation: If the client experiences severe cramping when the enema solution is introduced, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. A client should not be placed on a bedpan until after the rectal tube is removed. The rectal tube does not need to re-positioned or removed.

A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation? Remove the tubing immediately and discontinue the procedure. Lower the solution container and check the temperature and flow rate. Place the client on a bedpan in the supine position while receiving the enema. Reposition the rectal tube and check for any fecal content.

Lower the solution container and check the temperature and flow rate. Explanation: If the client complains of severe cramping when the enema solution is introduced, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. This assessment should precede removal of the tube or repositioning the client or the tube.

Which actions are important goals of a bowel training program for clients with spinal cord injuries? Select all that apply. Maintain soft stool consistency. Develop a routine method for stool evacuation. Prevent fecal impaction. Regain previous level of bowel independence.

Maintain soft stool consistency. Develop a routine method for stool evacuation. Prevent fecal impaction. Explanation: It is unlikely that a client who needs a bowel training program will regain his previous level of bowel independence. However, this does not mean that a client cannot create a new, independent norm for himself.

A nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer? Hypertonic Carminative Oil-retention Anthelmintic

Oil-retention Explanation: Oil-retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. A hypertonic enema draws water into the colon, which stimulates the defecation reflex. Carminative enemas help to expel flatus from the rectum and relieve distention secondary to flatus. Anthelmintic enemas are administered to destroy intestinal parasites.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? Peptic Ulcer Chronic Constipation Cirrhosis of the Liver Gastroesophageal Reflux Disease (GERD)

Peptic Ulcer Explanation: Any health problem that involves bleeding of the GI tract, such as peptic ulcer disease, may require fecal occult blood testing (FOBT). Constipation does not indicate a need for FOBT unless hardened stool is suspected of causing GI trauma. Similarly, GERD may require FOBT only if esophageal bleeding is suspected. Liver disease is not a common indication for FOBT.

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include? Plans to eat 4 ounces of protein 3 times per day. Will includes a pat of butter with eggs for breakfast. Plans to eat a snack of fruit twice per day. Will include fish one to two times per week.

Plans to eat a snack of fruit twice per day. Explanation: By snacking on fruits and vegetables, the client can increase fiber in the diet. The amount of fish, protein, and fat do not relate to increasing or absorbing fiber in the diet.

A client with lactose intolerance is experiencing abdominal distress, gas, and diarrhea after breakfast each morning. After reviewing the client's food journal, which meal should the nurse point out as a potential trigger? Fried eggs and toast Peanut butter protein bar and black coffee Fruit and plain bagel Sandwich with deli meat

Sandwich with deli meat Explanation: A client with lactose intolerance should be advised to not drink milk or milk products. Deli meats often contain casein, which is a milk protein. All other answer options do not contain milk products

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next? Measure the stoma using a stomal guide. Fold and clamp bottom of pouch. Attach new pouch to the ring of the faceplate. Shower, bathe, or wash peristomal area with mild soapy water.

Shower, bathe, or wash peristomal area with mild soapy water. Explanation: After removal of an existing ostomy appliance, the client should be taught to clean the peristomal area or shower or bathe. Other actions take place after cleansing.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? Position the client on his back and drape properly. Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Introduce solution quickly over a period of 3 to 5 minutes. Encourage the client to hold the solution for at least 20 minutes.

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Explanation: The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the physician. Stop the administration of the enema momentarily. Increase the flow of the enema until all of the solution has been administered.

Stop the administration of the enema momentarily. Explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? The graduate advises the client that the enema should not be expelled immediately. The graduate uses a room temperature solution. The graduate places the client in Fowler's position. The graduate takes this opportunity to teach about the function of the intestinal tract.

The graduate places the client in Fowler's position. Explanation: Placing the client in Fowler's position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? The stoma is pink. The stoma has a small amount of bleeding. The stoma is prolapsed. The stoma is on the abdominal surface.

The stoma is prolapsed. Explanation: If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed? The student had the client flex the knees when performing the assessment. The student sequenced from auscultation to inspection, and percussion to palpation. The student placed the client in supine position with the abdomen exposed. The student instructed the client to urinate before beginning the focused assessment.

The student sequenced from auscultation to inspection, and percussion to palpation. Explanation: The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination.

When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply. Elevate the bed to 15 degrees when using the bedpan. Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water. Encourage decreasing the amount of fiber in diet. Encourage the client to exercise once a week.

Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water. Explanation: Use of moist heat soothes the perineal area. Water is preferred because fluids with caffeine and sugars have a diuretic effect. When a client is using the bedpan, the head of the bed should be elevated to a minimum of 30 degrees. A low-fiber diet is recommended for a client with diarrhea. Clients require regular exercise to aid in defecation; once a week is not enough.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? Use water only. Use alcohol-based sanitizer. Use water and mild soap. Use mineral oil.

Use water and mild soap. Explanation: The nurse will teach the client to use water and mild soap to cleanse the stoma. Water only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing.

Which factor is related to developmental changes in bowel habits for older adult clients? Increase in dietary fiber can decrease peristalsis. Milk products cause constipation in clients with lactose intolerance. Weakened pelvic muscles lead to constipation. Older adults should peel fruits before eating.

Weakened pelvic muscles lead to constipation. Explanation: Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in older adults. Peeling fruit does not impact bowel habits in the older adults.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods? Whole wheat spaghetti and broccoli Cream of wheat and applesauce Soda crackers and chicken noodle soup Hot tea and flavored water

Whole wheat spaghetti and broccoli Explanation: To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? Asparagus and turnip Fish and dried lentils Yogurt and buttermilk Onions and garlic

Yogurt and buttermilk Explanation: Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation? reduces elasticity in intestinal walls and slows motility affects absorption of fat-soluble vitamins causes periodic bleeding and tissue trauma develops healthier bowel elimination patterns

affects absorption of fat-soluble vitamins Explanation: Elderly clients who use mineral oil to prevent or relieve constipation need to be informed that prolonged use affects the absorption of fat-soluble vitamins such as A, D, E, and K. Bleeding and tissue trauma does not occur due to use of mineral oil for constipation but during the digital removal of faction. Use of mineral oil for constipation does not develop healthier bowel elimination patterns, but the use of bulk-forming products containing psyllium or polycarbophil does. Loss of elasticity in intestinal walls and slower motility is due to old age, not the use of mineral oil.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: auscultation. percussion. light palpation. deep palpation.

auscultation. Explanation: When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. dark brown light brown black clay colored yellow

black clay colored yellow Explanation: The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate? stopping the infusion removing the tubing immediately reassuring the client that cramping is normal briefly clamping the tubing while the client breathes deeply

briefly clamping the tubing while the client breathes deeply Explanation: Some clients experience cramping when receiving a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion. A slower infusion rate may be necessary. Other choices are incorrect.

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? cleansing enema retention enema carminative enema return-flow enema

cleansing enema Explanation: The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply. dark brown light brown black clay colored yellow

dark brown light brown Explanation: The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan), and yellow are considered abnormal colors for adult stool.

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? dark pink and moist red and dry off-white or pale pink. dark or purple-blue.

dark pink and moist Explanation: A healthy stoma is dark pink to red and moist. Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia.

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema? promotes bowel movement without irritation effect lubricates and softens the stool draws fluid from body tissues into the bowel causes chemical irritation of the mucous membranes

draws fluid from body tissues into the bowel Explanation: A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? barium studies, endoscopic examination, fecal occult blood test fecal occult blood test, barium studies, endoscopic examination barium studies, fecal occult blood test, endoscopic examination endoscopic examination, barium studies, fecal occult blood test

fecal occult blood test, barium studies, endoscopic examination Explanation: There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag? liquid watery formed none

formed Explanation: A colostomy is an opening of the large intestine that allows formed feces from the colon to exit through the stoma.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? mineral oil tap water soap and water hypertonic saline

hypertonic saline Explanation: The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply. lentils shrimp onions cabbage pork chops chicken nuggets

lentils onions cabbage Explanation: Lentils, onions, and cabbage are known to produce gas. Meats are generally not associated with formation of gas.

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs? water soap normal saline oil

oil Explanation: Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? palpation percussion auscultation inspection

palpation Explanation: The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository? past the internal sphincter just past the opening of the anus far enough to still visualize the end of the suppository until the client reports feelings of discomfort

past the internal sphincter Explanation: To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client? increases the volume of the stool, making defecation easier removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps

removes hardened fecal impactions from the rectum Explanation: Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding? primary constipation secondary constipation iatrogenic constipation pseudoconstipation

secondary constipation Explanation: The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition.

A nurse is caring for a 65-year-old woman who has undergone a hernia operation. The client receives morphine via patient-controlled anesthesia for postoperative pain. The client also receives sulfamethoxazole-trimethoprim every 12 hours to treat a urinary tract infection, and an iron supplement for anemia. The client is on mobility restrictions because of the opioids. The client explains that while she usually passes stool once per day, she has passed stool four times today. The health care provider has diagnosed diarrhea. What is most likely contributing to this outcome? morphine iron supplement immobility sulfamethoxazole-trimethoprim

sulfamethoxazole-trimethoprim Explanation: Antibiotics, such as sulfamethoxazole-trimethoprim, can cause diarrhea. Morphine, iron supplement, and immobility are likely causes of constipation.

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be prescribed? vitamin A vitamin B12 vitamin C vitamin D

vitamin B12 Explanation: The nurse anticipates that vitamin B12 will be prescribed for a client with this type of ostomy, an ileostomy. This helps prevent vitamin B12-deficiency anemia, which can occur because ileostomies are placed before the terminal ileum where vitamin B12 is absorbed.