Chapter 38: Bowel Elimination
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:
liquid consistency.
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
Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply.
onions lentils cabbage
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
The nurse is administering a rectal suppository. How far will the nurse insert the suppository?
past the internal sphincter
When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:
physiologic or lifestyle changes in the client.
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
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.
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 nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?
"All four abdominal quadrants auscultated. Inaudible bowel sounds."
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 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?
"Only if the stool has not been contaminated by urine."
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 detects heme, a type of iron compound in blood in the stool."
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 test detects heme, an iron compound in blood within the stool."
The nurse has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse?
"Wait to do the test 3 days after your finish menstruating."
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?"
"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.
-False 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 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.
The nurse is reviewing prescriptions to irrigate an ostomy. Which clients can have their ostomy irrigated? Select all that apply.
A client with a left-sided end colostomy A client with a sigmoid colostomy
Which symptom is a known side effect of antibiotics?
Diarrhea
A nurse assesses a client who has a PRN (as-needed) prescription for a small-volume cleansing enema. What result would contraindicate the safe administration of an enema? Select all that apply.
Anal fissures Platelet count of 19,500/mm3 (195.00 ×109/L)
A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure?
Assist the client to a 30- to 45-degree position, unless this is contraindicated.
A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?
Attempt to irrigate the NG tube with water or normal saline.
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
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?
Before removing the tube, discontinue suction and separate the tube from suction.
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?
Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.
An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?
Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate
A student nurse studying human anatomy knows that a structure of the large intestine is the:
Cecum
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 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 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.
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.
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.
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.
A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client?
History of facial fractures
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
The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?
Hypertonic saline
A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?
If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?
Inadequate intake of liquid
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.
The nurse is educating a parent who has called the clinic reporting the child is experiencing diarrhea. What suggestions should the nurse provide to the parent? Select all that apply.
Provide a diet high in complex carbohydrates, meats, fruits, and vegetables Replace fluids that have sodium chloride, potassium, and glucose Assume an age appropriate diet when possible
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
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.
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
Stop the procedure, monitor heart rate and blood pressure.
The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?
The NG tube is in the client's airway.
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 prolapsed.
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 sequenced from auscultation to inspection, and percussion to palpation.
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?
Togurt and buttermilk
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. Washing the stoma and surrounding skin with mild soap and water and patting it dry can preserve skin integrity. 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.
Which factor is related to developmental changes in bowel habits for older adult clients?
Weakened pelvic muscles lead to constipation.
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
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.
a positive family history age 50 and older a history of inflammatory bowel disease
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
Which medication causes constipation?
iron supplements
A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?
large-volume cleansing enema with hypotonic solution
