chapter 38: bowel elimination PrepU quiz

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."

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

- "The client expresses interest in learning self-care." - "The client is willing to look at the stoma." - "The client makes neutral or positive statements about the ostomy."

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

- 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

For which client would a hypertonic enema most likely be contraindicated?

A client with renal impairment

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 registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?

Emptying a client's ileostomy appliance

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 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 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 a snack of fruit twice per day

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 student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily.

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 and mild soap

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

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago

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.

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.

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus?

"Certain vegetables can cause flatus, as they are more difficult to digest."

A client diagnosed with colorectal cancer reports constipation to the nurse. Which teaching will the nurse provide to help the client identify sign(s) or symptom(s) of constipation? Select all that apply

- Watch for liquid bowel movements after days with none. - You will urinate less often or not at all. - You may experience pain on defecation.

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

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

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

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

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.

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.

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

Which symptom is a known side effect of antibiotics?

diarrhea

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

skin turgor response 5 seconds