Funds Chp 37 Bowel Elimination

A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior? A. "When he does this, scold him and he will quit." B. "I don't understand why this child is losing control." C. "This is normal when a child this age is hospitalized." D. "I will have to call the doctor and report this behavior."

Ans: C Feedback: Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet trained often regress and experience soiling when hospitalized, and scolding or acting disgusted only reinforces the behavior.

A client's last bowel movement was four days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the patient in anticipation of administering a cleansing enema? a) Right side‐lying b) Prone c) Supine d) Left side‐lying

Ans: D When administering a cleansing enema, the client is most often positioned in a left side‐lying (Sims') position, though positioning has not been shown to appreciably alter the result of a cleansing enema.

A nurse caring for patients with bowel alterations formulates a nursing diagnosis for a patient with a new ileostomy. Which diagnosis is most appropriate? a. Disturbed Body Image b. Constipation c. Delayed Growth and Development d. Excess Fluid Volume

Ans: A Feedback: An ileostomy may cause disturbed body image due to the invasive nature of the procedure and the presence of the stoma. Constipation does not normally occur with an ileostomy because the drainage is liquid. Growth and development are not generally affected by the formation of an ileostomy. Excess fluid volume is unlikely to occur because the drainage is liquid and probably continual.

A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby? A. Yellow, loose, odorless B. Brown, paste-like, some odor C. Brown, formed, strong odor D. Black, semiformed, no odor

Ans: A Feedback: Breast-fed babies have more frequent stools, and the stools are yellow to golden and loose, usually with little odor. Breast-fed babies can normally have 2 to 10 stools per day.

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A. Golden yellow and loose B. Dark brown and firm C. Yellow-brown and pasty D. Green and mucusy

Ans: A Feedback: Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and usually have little odor. With formula or cow's milk feedings, infants' stools vary from yellow to brown and are pasty in consistency.

Which is an expected outcome for a client undergoing a bowel training program? A. Have a soft, formed stool at regular intervals without a laxative. B. Continue to use laxatives, but use one less irritating to the rectum. C. Use oil-retention enemas on a regular basis for elimination. D. Have a formed stool at least twice a day for two weeks.

Ans: A Feedback: Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or fluid intake. to produce the elimination of a soft, formed stool at regular intervals without a laxative.

A nurse is scheduling diagnostic studies for client. Which test would be performed first? A. Fecal occult blood test B. Barium study C. Endoscopic exam D. Upper gastrointestinal series

Ans: A Feedback: Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo multiple studies. They should follow a logical sequence when more than one test is required for accurate diagnosis; that is, fecal occult blood tests to detect gastrointestinal bleeding; barium studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions; and endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide biopsy tissue samples.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on: A. Habitual laxative use is the most common cause of chronic constipation. B. If laxatives are not effective, the client should begin to use enemas. C. A laxative that works by a different method should be used. D. Chronic constipation is nothing to be concerned about.

Ans: A Feedback: Occasional use of laxatives is not harmful for most people, but they should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation.

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client? A. Constipation B. Diarrhea C. Deficient fluid volume D. Excessive fluid volume

Ans: A Feedback: Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will be absorbed in the colon.

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a. Have the patient follow a clear liquid diet 24 to 48 hours before the test. b. Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1. c. Prepare the patient for the use of general anesthesia during the test. d. Explain that barium contrast mixture will be given to drink before the test.

Ans: A Feedback: Preparation for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day 2 of the test, or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a short period of time. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small bowel series of tests.

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document? A. "Ileostomy bag half filled with liquid feces." B. "Ileostomy bag half filled with hard, formed feces." C. "Colostomy bag intact without feces." D. "Colostomy bag filled with flatus and feces."

Ans: A Feedback: 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 nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A. Increased bowel sounds B. Abdominal tenderness C. Areas of distention D. Muscular resistance

Ans: A Feedback: The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.

A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction? A. Inserted a lubricated, gloved finger into the rectum. B. Obtain a sharp intestinal x-ray. C. Insert a lubricated rectal tube into the rectum. D. Administer an oil retention enema into the rectum.

Ans: A Feedback: The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

Ans: A Feedback: The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

A nurse is following a physician's order to irrigate the NG tube of a client. Which of the following is a recommended guideline in this procedure A. Assist client to 30- to 45-degree position, unless this is contraindicated. B. Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. C. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. D. If unable to irrigate the tube, reposition client and attempt irrigation again; inject 20 to 30 mL of air and aspirate again.

Ans: A Feedback: To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.

What are two essential techniques when collecting a stool specimen? A. Hand hygiene and wearing gloves B. Following policies and selecting containers C. Wearing goggles and an isolation gown D. Using a no-touch method and toilet paper

Ans: A Feedback: Use of medical aseptic techniques when collecting a stool specimen is imperative. Hand hygiene, before and after wearing rubber gloves, is essential.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following? A. An increase in the client's blood pressure B. A decrease in the client's blood pressure C. An increase in the client's respiratory rate D. A decrease in the client's respiratory rate

Ans: A Feedback: When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart; this act elevates the client's blood pressure.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? a) Disconnect the nasogastric tube from suction during the assessment of bowel sounds. b) Allow the low intermittent suction to continue during the assessment of bowel sounds. c) Apply continuous suction to the nasogastric tube during assessment of bowel sounds. d) Disconnect the nasogastric tube from the suction for one hour prior to the assessment of bowel sounds

Ans: A If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds.

Which of the following clients is most likely to require interventions in order to maintain regular bowel patterns? a) A client whose neuropathic pain requires multiple doses of opioids each day b) A client who has a history of atrial fibrillation requiring daily anticoagulants c) A woman 59 years of age who has recently begun hormone replacement therapy d) A client with hypertension who takes a diuretic and adrenergic blocker each morning

Ans: A Opioids have a very high potential to cause constipation. Anticoagulants, hormone replacements, diuretics, and ‐blockers are not among the medications commonly implicated in cases of constipation.

A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take? a) Facilitate a more private setting, such as assisting the client to a bathroom. b) Obtain a diet change order to increase the amount of fiber in the client's meals. c) Administer a normal saline enema after obtaining the relevant order. d) Position the client on his or her side and administer a glycerin suppository.

Ans: A The client's last bowel movement was one day earlier, so pharmacologic interventions such as suppositories or enemas are not likely warranted at this time. A change in diet may prove helpful, but the nurse's first action should be to provide a setting that is more conducive to having a bowel movement.

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? a) Cleansing enema b) Carminative enema c) Retention enema d) Return‐flow enema

Ans: A 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.

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

Ans: A This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance.

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest c. A patient who has diarrhea d. A patient who has gastroenteritis e. A patient who has an early bowel obstruction f. A patient who has paralytic ileus caused by surgery

Ans: A,B,F Feedback: Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Jensen, 2011)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply. a. Draw up 30 mL of saline solution into the syringe. b. Unclamp the suction tubing near the connection site to instill solution. c. Place the tip of the syringe in the tube to gently insert saline solution. d. Place syringe in the blue air vent of a Salem sump or double-lumen tube. e. After instilling irrigant, hold the end of the NG tube over an irrigation tray. f. Observe for return flow of NG drainage into an available container.

Ans: A,C,E,F Feedback: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container

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? a) Dark or purple‐blue. b) Dark pink and moist. c) Red and dry. d) Off‐white or pale pink.

Ans: B A healthy stoma is dark pink to red and moist. Pallor may suggest anemia and a dark appearance may indicate ischemia.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? a) Laxative b) Antidiarrheal agent c) Suppository d) Antiflatulence agent

Ans: B Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client? A. Fowler's B. Sims' C. Prone D. Sitting

Ans: B Feedback: A reclining position on the left side (Sims' position) is recommended. The head may be slightly elevated, but Fowler's position should be avoided because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing.

A client has had frequent watery stools (diarrheA. for an extended period of time. The client also has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate? A. Imbalanced Nutrition: Less than Body Requirements B. Deficient Fluid Volume C. Impaired Tissue Integrity D. Impaired Urinary Elimination

Ans: B Feedback: Bowel elimination problems may also affect other areas of human functioning. For example, excessive diarrhea causes loss of body fluid, with resulting decreased skin turgor and concentrated urine. Deficient Fluid Volume is an appropriate nursing diagnosis based on the data.

A nurse is providing discharge instructions for a client with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care? A. During the first six to eight weeks after surgery, eat foods high in fiber. B. Drink at least two quarts of fluids, preferably water, daily. C. Use enteric-coated or sustained-release medications if needed. D. Use a mild laxative if needed.

Ans: B Feedback: During the first six to eight weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (e.g., 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 two quarts 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 nurse is irrigating the colostomy of a patient and is unable to get the irrigation solution to flow. What would be the nurse's next action in this situation? a. Assist the patient to a prone position on a waterproof pad and try again. b. Check the clamp on the tubing to make sure that the tubing is open. c. Quickly pull the cone from the stoma and check for bleeding. d. Remove the equipment and call the primary care provider.

Ans: B Feedback: If irrigation solution is not flowing, the nurse should first check the clamp on the tubing to make sure the tubing is open. Next, the nurse should gently manipulate the cone in the stoma and check for a blockage of stool. If there is a blockage, the nurse should remove the cone from the stoma, clean the area, and gently reinsert. Alternately, the nurse could assist the patient to a side-lying or sitting position in bed, place a waterproof pad under the irrigation sleeve, and place the drainage end of the sleeve in a bedpan.

A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ... A. Allergic to sugar B. Lactose intolerant C. Experiencing infectious diarrhea D. Deficient in fiber

Ans: B Feedback: Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products.

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem? A. It is painful to sit on a bedpan. B. The position does not facilitate downward pressure. C. The position encourages the Valsalva maneuver. D. The cause is unknown and requires further study.

Ans: B Feedback: Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult.

During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A. Constipation B. Perceived constipation C. Risk of constipation D. Bowel incontinence

Ans: B Feedback: The most appropriate nursing diagnosis for the client is perceived constipation, because the client has made a self-diagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal frequency of defecation accompanied by a difficult or incomplete passage of stool (and/or passage of excessively hard, dry stool). Risk of constipation can be diagnosed if a client exhibits factors that predispose him or her for developing constipation. Bowel incontinence would be indicated if the client was experiencing an involuntary passage of stool.

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

Ans: B In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. The other responses are incorrect documentation.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which of the following diets? a) A diet lacking in meat and poultry products b) A diet lacking in fruits and vegetables c) A diet consisting of whole grains, seeds, and nuts d) A diet lacking in glucose and water

Ans: B The incidence of constipation tends to be high among clients whose dietary habits lack sufficient raw fruits and vegetables, whole grains, seeds, and nuts, all of which contain adequate fiber. Dietary fiber, which becomes undigested cellulose, is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. A diet lacking in glucose and water will cause dehydration first and then constipation, depending on other constituents of the diet. Diets consisting of whole grains, seeds, and nuts provide fiber, which help in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.

A nurse is assessing the stoma of a client with an ostomy. Which of the following interventions should the nurse perform when providing peristomal care to the client to preserve skin integrity? a) Avoid using commercial skin preparations. b) Wash it with soap and water. c) Clean it with a dry, cotton bandage. d) Avoid applying a barrier substance.

Ans: B 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 of the following factors is related to developmental changes in bowel habits for older adult clients? a) Older adults should peel fruits before eating b) Weakened pelvic muscles lead to constipation c) Milk products cause constipation in clients with lactose intolerance d) Increase in dietary fiber can decrease peristalsis

Ans: B 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.

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 which of the following? a) Percussion b) Auscultation c) Deep palpation d) Light palpation

Ans: B 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 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 of the following responses by participants indicates a correct understanding of the material? Select all that apply. a) "The patient uses spray deodorant several times an hour to mask odor." b) "The client is willing to look at the stoma." c) "The client makes neutral or positive statements about the ostomy." d) "The client agrees to take prescribed antidepressants." e) "The client expresses interest in learning self‐care."

Ans: B, C, E

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. A patient who is taking narcotics for pain b. A patient who is taking laxatives c. A patient who is taking diuretics d. A patient who is dehydrated e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

Ans: B,E,F Feedback: Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate (Augmentin), laxatives, or over-the counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? A. "Just give it a few more days and you should be fine." B. "Well, that shouldn't happen. Let me recommend a good laxative for you." C. "When you increase fiber in your diet, you also need to increase liquids." D. "I will tell the doctor you are having problems; maybe he can help."

Ans: C Feedback: A combination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has been shown to be as effective as medications in controlling constipation. Caution the client to avoid increasing fiber intake without drinking enough fluids because this can lead to a bowel obstruction.

A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client? A. Oil retention enema B. Carminative enema C. Anthelmintic enema D. Nutritive enema

Ans: C Feedback: Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish fluids and nutrition rectally.

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

Ans: C Feedback: 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 is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation? a. Elevate the head of the bed 30 degrees and reposition the rectal tube. b. Place the patient in a supine position and modify the amount of solution. c. Lower the solution container and check the temperature and flow rate. d. Remove the rectal tube and notify the primary care provider.

Ans: C Feedback: If the patient complains of severe cramping with introduction of an enema solution, 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 nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a. Reassure the patient that this is a normal finding with a new ostomy. b. Notify the primary care provider that the stoma is prolapsed. c. Have the patient rest for 30 minutes to see if the prolapse resolves. d. Remove the appliance and redo the procedure using a larger appliance.

Ans: C Feedback: If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the physician. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A. Routine urinalysis B. Chest x-ray C. Stool sample D. Sputum sample

Ans: C Feedback: Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be confirmed by a stool sample.

A nurse is providing care to a client who has undergone a colonoscopy. Which of the following would be most appropriate for the nurse to do after the procedure? A. Avoid giving solid food B. Administer a laxative to the client C. Monitor for rectal bleeding D. Limit oral fluid intake

Ans: C Feedback: The nurse should monitor the client for rectal bleeding after a colonoscopy. 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 patient has a fecal impaction. The nurse correctly administers an oil-retention enema by: a. Administering a large volume of solution (500-1,000 mL) b. Mixing milk and molasses in equal parts for an enema c. Instructing the patient to retain the enema for at least 30 minutes d. Administering the enema while the patient is sitting on the toilet

Ans: C Feedback: The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.

A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next? A. Notify the physician immediately. B. Ask another nurse to check her findings. C. Nothing; this is normal. D. Recheck the bag in two hours.

Ans: C Feedback: Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after surgery, usually within two to five days.

A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure, the patient tells the nurse she is feeling dizzy and nauseated, and then she vomits. What should be the nurse's next action? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the physician. c. Stop the procedure, assess vital signs, and notify the physician. d. Stop the procedure, wait five minutes, and then resume the procedure.

Ans: C Feedback: When a patient complains of dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the physician. The vagal nerve may have been stimulated.

An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea? A. Heart tones B. Lung sounds C. Skin turgor D. Activity level

Ans: C Feedback: When infants and children become ill, they lose most fluids from their extracellular compartment, which quickly leads to dehydration. The nurse would assess skin turgor to identify this problem.

A nurse is performing an abdominal assessment of a client before administering a large‐volume cleansing enema. Which of the following assessment techniques would be performed last? a) Percussion b) Auscultation c) Palpation d) Inspection

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

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which of the following nursing diagnoses? a) Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence b) Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency c) Bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate d) Fecal retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

Ans: C The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the abdomen. Which of the following would the nurse perform next? a) Perirectal examination b) Palpation c) Auscultation d) Percussion

Ans: C The nurse should conduct auscultation after inspection, because palpation and percussion may disturb the bowel sounds. Auscultation of the abdomen must be performed before percussion or palpation. Percussion or palpation of the abdomen may stimulate intestinal activity, therefore changing the quality or frequency of bowel sounds. A perirectal examination is performed last.

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? a) Distends rectum and irritates local tissue b) Irritates local tissue c) Distends rectum and moistens stool d) Lubricates and softens stool

Ans: D Cottonseed, olive oil, or mineral oil lubricates and softens the stool so that it can be expelled more easily during a retention enema. Tap water and normal saline solution distend the rectum and moisten the stool; whereas, a soap and water solution not only distends the rectum and moistens the stool but also irritates the local tissue. A hypertonic saline solution irritates local tissue.

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? a) "That's correct, but be sure that you don't increase your laxative doses over time." b) "Most older adults only have a bowel movement every two to three days, actually, so I'd encourage you to taper off your laxatives." c) "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." d) "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

Ans: D Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician ordered the following tests: (A. barium enema, (B. fecal occult blood test, (C. endoscopic studies, and (d. upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a. c, b, d, a b. d, c, a, b c. a, b, d, c d. b, a, d, c

Ans: D Feedback: A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change? A. Decrease high-fiber foods B. Decrease amount of fluids C. Omit fruits if eating vegetables D. Nothing; this is a good diet

Ans: D Feedback: A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel elimination. Intake of the foods described makes the feces more bulky, so they move through the intestine more quickly. The stool is softer and the time to absorb toxins is decreased (toxins are believed to have a role in the development of colon cancer).

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition? A. The peristomal skin is excoriated or irritated because the appliance is cut too large. B. The system has leaks or poor adhesion leading to noticeable odor. C. The bag continues to come loose and become inverted. D. The stoma is protruding into the bag and may become twisted.

Ans: D Feedback: During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if 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.

A nurse is teaching a patient with frequent constipation how to implement a bowel-training program. What is a recommended teaching point? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1,000 mL c. Administering an enema once a day to stimulate peristalsis d. Allowing ample time for evacuation

Ans: D Feedback: For a bowel-training program to be effective, the patient must have ample time for evacuation (usually 20-30 minutes). Fluid intake is increased to 2,500 to 3,000 mL, food high in bulk is recommended as part of the program, and a daily enema is not administered in a bowel-training program. A cathartic suppository may be used 30 minutes before the patient's usual defecation time to stimulate peristalsis.

What is occult blood? A. Bright red visible blood B. Dark black visible blood C. Blood that contains mucus D. Blood that cannot be seen

Ans: D Feedback: Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a Hematest.

A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A. Stool-softening laxatives, such as Colace B. Increasing fluid intake to 3,000 mL/day C. Drinking fluids with a high sugar content D. Eating fermented products, such as yogurt

Ans: D Feedback: Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To promote the return of normal flora, the nurse can recommend an intake of fermented dairy products, such as buttermilk or yogurt.

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

Ans: D The procedure may stimulate a vagal response, which increases parasympathetic stimulation.

Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly? A. Hard, formed B. Black, tarry C. Soft, watery D. Dry, odorous

Ans: C Feedback: About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When absorption does not occur properly, such as when the waste products pass through the large intestine rapidly, the stool is soft and watery

A nurse prepares to assist a patient with her newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages."

Ans: D,E,F Feedback: Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area. should be kept clean and dry.

The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason? A. Detect abdominal masses B. Determine abdominal firmness C. Assess softness of abdominal muscles D. Assess degree of abdominal distention

Ans: A Feedback: The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention.

Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order. 1. Cleanse entire perianal area and pat dry. 2. Apply skin protectant and allow it to dry. 3. Separate buttocks and apply the pouch to the anal area. 4. Attach the pouch to a urinary drainage bag. 5. Hang the drainage bag below the patient. A. 2, 3, 4, 5, 1 B. 3, 4, 5, 1, 2 C. 1, 2, 3, 4, 5 D. 5, 4, 3, 2, 1

Ans: C Feedback: A nurse would not be able to determine if the entire intestinal tract is clear

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? A. Pallor B. Purple-blue C. Irritation and bleeding D. Dark red and moist

Ans: D Feedback: The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple-blue color (possible ischemia), or bleeding.

Which of the following medical diagnoses is most likely to necessitate testing for fecal occult blood? a) Peptic ulcer b) Cirrhosis of the liver c) Gastroesophageal reflux disease (GERD) d) Chronic constipation

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

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition? a) The stoma is protruding into the bag and may become twisted. b) The bag continues to come loose and become inverted. c) The peristomal skin is excoriated or irritated because the appliance is cut too large. d) The system has leaks or poor adhesion leading to noticeable odor.

Ans: A During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if 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.

A nurse is caring for a postpartum patient who has stitches in the perineum from an episiotomy (surgically planned incision to prevent vaginal tears). Which medication would the nurse most likely administer to this patient? a. A stool softener (ColacE. b. An osmotic laxative (Miralax) c. A bulk-forming laxative (Metamucil) d. An emollient laxative (mineral oil)

Ans: A Feedback: Although all the choices are laxatives that would soften the stool and make it easier to expel, a stool softener, such as Colace, is the one recommended for a patient who must avoid straining. In this case, it would help to prevent disturbing the stitches in the perineum.

A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment? A. It is the most painful assessment method B. It is the most embarrassing assessment method C. To allow time for the examiner's hands to warm D. It disturbs normal peristalsis and bowel motility

Ans: D Feedback: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.

Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet? a) Lettuce salad b) Baked potato c) Chicken d) Custard

Ans: D The client should not be permitted to eat the custard because it is prepared using milk. Clients who are lactose intolerant cannot digest the simple sugar lactose found in milk and milk products