Bowel Elimination Prep-U

The nurse is caring for a client with a stoma that is pink in color and dry. Which action will the nurse take?

Apply petroleum-based ointment.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

A nurse is providing discharge instructions for a client with a new colostomy. Which is a recommended guideline for long-term ostomy care?

Drink at least 2 quarts (1.9 L) of fluids, preferably water, daily. Use enteric-coated or sustained-release medications if needed. Use a mild laxative if needed. During the first 6 to 8 weeks after surgery, eat foods high in fiber. Rationale: During the first 6 to 8 weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (foods with skins, seeds, and shells) as well as any other foods that cause diarrhea or excessive flatus. By gradually adding new foods, the ostomy client can progress to a normal diet. The nurse should urge clients to drink at least 2 quarts (1.9 L) of fluids, preferably water, daily. The use of liquid, chewable, or injectable forms rather than long-acting, enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are dangerous because they may cause severe fluid and electrolyte imbalance.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Habitual laxative use is the most common cause of chronic constipation.

Which is an expected outcome for a client undergoing a bowel training program?

Have a soft, formed stool at regular intervals without a laxative.

During the physical examination of a client, the nurse percusses the abdomen. In which abdominal quadrant should the nurse expect to hear tympany?

LUQ Rationale: The stomach is in the LUQ and contains more air than the small or large intestine. The normal percussion sound heard in the other three quadrants is a hollow sound that is not quite as high-pitched as tympany, reflecting a mixture of air and fluid in the intestines.

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?

Lower solution container and check temperature and flow rate.

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

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

Perform a screening test on stool samples.

A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?

Rotate the catheter tip inside the stoma. Rationale: The nurse could also try to milk the catheter in order to clear it. If all the above actions fail, the nurse should remove the catheter, rinse it, and try again.

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next?

Shower, bathe, or wash peristomal area with mild soapy water. Measure the stoma using a stomal guide. Fold and clamp bottom of pouch. Attach new pouch to the ring of the faceplate.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.

The nurse reviews information about defecation with a group of nursing students in preconference prior to their clinical experience for the day. What response by the students indicate that the information given by the nurse is understood?

The center in the medulla and another center in the spinal cord govern the reflex to defecate. Defecation refers to the emptying of the small intestine. When stimulation of the sympathetic nervous system occurs, the internal anal sphincter relaxes and the colon contracts, sending fecal content to the rectum. Rectal distention leads to a decrease in the pressure in the rectum and this causes the muscles to stretch and thereby stimulate the defecation reflex. Rationale: Two centers govern the reflex to defecate. One center is in the medulla, and a subsidiary center is in the spinal cord. Defecation refers to the emptying of the large intestine. When parasympathetic, not sympathetic, stimulation occurs, the internal anal sphincter relaxes and the colon contracts. Rectal distention leads to an increase in intrarectal pressure, causing the muscles to stretch and thereby stimulating the defecation reflex.

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply.

The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The client should be instructed not to place toilet tissue in the bedpan or specimen container. Medical aseptic techniques are always followed. Handwashing is performed before and after glove use when handling a stool specimen. The client should be asked to defecate into a clean bedpan or toilet bowl, depending on the nature of the study. Generally, 2 inches of formed stool or 20 to 30 mL of liquid stool is sufficient for a stool specimen. Rationale: A specimen container would need to be placed in the commode. Usually 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient for a stool specimen.

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly?

The nurse administers the oil-retention enema at body temperature. The nurse instructs the client to retain the oil for at least 30 minutes. The nurse administers a cleansing enema after the oil-retention enema.

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer?

age 50 and older a positive family history a history of inflammatory bowel disease a diet high in fruits, vegetables, and whole grains.

The nurse is obtaining a health history from a client. The client states, "I have to take laxatives every day or I don't have a bowel movement." What primary risk does the nurse need to assess for among clients who use laxatives long term?

dependence

A nurse is scheduling diagnostic studies for a client. Which test would be performed first?

fecal occult blood test 1. Fecal occult blood tests to detect gastrointestinal bleeding 2. Barium studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions 3. Endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide biopsy tissue samples.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying (sims)

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?

fecal occult blood test, barium studies, endoscopic examination

A group of nursing students is reviewing the common agents used to relieve constipation. The group demonstrates understanding of this information when they identify which remedies as examples of stimulant laxatives?

Castor oil Bisacodyl Senna Metamucil (bulk laxative) Milk of magnesia (saline laxative)

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?"

A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch?

1/3 full

The nurse is checking the placement of a nasogastric tube and aspirates for gastric contents. The nurse checks the pH of the aspirate and determines that the tube is in the stomach when she gets which pH measurement?

5 Rationale: If the pH of the aspirated contents is 5 or less, then it can be assumed that the tube is in the stomach because gastric contents are acidic.

A client with terminal cancer is taking high doses of a narcotic for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

Increase fiber in the diet.

The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply.

The autonomic nervous system innervates the muscles of the colon. Peristalsis occurs every 3 to 12 minutes. Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people. Mass peristalsis often occurs after food has been ingested.

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?

The position does not facilitate downward pressure.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water. Rationale: Another way to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.

For which of the following clients would digital removal of stool be contraindicated?

a client recovering from prostate surgery

What is fecal occult blood?

blood that can't be seen

A student nurse studying human anatomy knows that a structure of the large intestine is the

cecum ileum jejunum duodenum Rationale: The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum. The small intestine consists of the duodenum, jejunum, and ileum.

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

What are 2 essential techniques when collecting a stool specimen?

hand hygiene and wearing gloves

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?

increased bowel sounds

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?

lubricates and softens stool

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?

oil

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

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?

removes hardened fecal impactions from the rectum

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 narcotics. 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?

sulfamethoxazole-trimethoprim morphine iron supplement immobility Rationale: Antibiotics are more than likely to cause diarrhea, the others cause constipation

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather?

tap water

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 B12

A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma?

water and mild soap saline mineral oil alcohol-based sanitizer

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 (to red) and moist Rationale: Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia.

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?

Ensure that the client fasts 6 to 12 hours before the test as per policy.

The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client?

Constipation Rationale: Fluid intake issues would be secondary to the primary cause. Diarrhea does not result from peristalsis.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

Peptic Ulcer

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?

Monitor for rectal bleeding Rationale: The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure.

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document?

"Ileostomy bag half filled with liquid feces." Rationale: The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid. A colostomy is when a portion of the large intestine is diverted through the abdominal wall.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

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) Rationale: 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?

50-year-old client with a family history of polyps Rationale: Screenings should start at 50 years old and continue every 10 years thereafter.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg Rationale: Pt also cannot consume citrus fruits or juices.

A group of nursing students is reviewing the common agents used to relieve constipation. The group demonstrates understanding of this information when they identify which remedies as examples of stimulant laxatives? Select all that apply.

Castor oil Bisacodyl Senna

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

Clamp the tube for a brief period and resume at a slower rate.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

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 Rationale: 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.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?

Insert a lubricated, gloved finger into the rectum.

A nurse is preparing to administer a large-volume enema to a client. The client and enema have been prepared. Place the following steps in the order in which the nurse would perform them.

Lubricate 2 to 3 in (5 to 8 cm) of the tip of the rectal tube with water-soluble lubricant. Separate the buttocks to visualize the anus. Have the client take a slow, deep breath. Gently insert the tube directing the tip toward the umbilicus. Open the clamp on the solution tubing while holding the tube in the rectum.

The nurse is preparing to insert a nasogastric tube for a client needing decompression. Which method would be most appropriate for the nurse to use to determine the length of tubing to be inserted?

Measure from the tip of earlobe to tip of nose to the tip of xiphoid process. Measure from the bridge of the nose to the nipple line to the umbilicus. Measure from the earlobe to the sternum and add 3 in (8 cm). Measure from the nasal opening to the chin to the sternal notch.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

Refrain from eating red meat 3 days before testing.

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of statement describes this condition?

The stoma is protruding into the bag and may become twisted. Rationale: During prolapse, the stoma is protruding into the bag. 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 physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma which will require a surgical intervention. The peristomal skin is excoriated or irritated because the appliance is cut too large is not associated with a prolapse stoma. The system has leaks or poor adhesion leading to noticeable odor is related to poor adhesion and not related to the prolaspe stoma. The bag continues to come loose and become inverted is related to the bag appliance and not the stoma.

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

age 50 and older a positive family history a history of inflammatory bowel disease

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

sims

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

sims

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds Rationale: Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention.

A 7-month-old infant recently underwent a bowel resection for an isolated perforation. The surgeons removed most of the client's ileum. The remaining small intestine was spared, and the large intestine remains intact. Based on the nurse's knowledge of digestion, the nurse knows that the client will likely have problems with which type of nutrient absorption?

some vitamins and iron