NU140- Chapter 38 Bowel Elimination

Anus

opening at the end of anal canal

Ileostomy

opening into the small intestine allows fecal content from the ileum to be eliminated through the stoma

The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk?

Encourage physical activity to improve bowel regularity.

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."

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states,"I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse?

"Children vary in their readiness but daytime bowel control may be attained at 30 months."

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct?

"I will administer enemas until the enema return is without stool."

The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount."

The nurse is preparing to administer a hypertonic saline enema. How much should the nurse prepare to administer?

120 mL

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

Laxative

drug used to induce emptying of the intestinal tract

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?

Antidiarrheal agent

Which symptom is a known side effect of antibiotics?

Diarrhea

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?

Hyperactive bowel sounds

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

Inspection Auscultation Percussion Palpation

Defecation

emptying of the intestinal tract; synonym for bowel movement

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.

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.

Bowel incontinence

the inability of the anal sphincter to control the discharge of fecal and gaseous material

The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. The nurse would intervene if which food item is included on the client's tray?

Sliced red apples

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid?

brussels sprouts

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.

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.

A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?

brown rice

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."

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

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

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 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

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.

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 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 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 needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?

Reinstruct the client on use of collection container for next bowel movement.

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 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.

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply.

The client has a history of chronic renal failure. The client has an elevated phosphorus level. The client has a history of left sided heart failure.

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.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.

The nurse places the client in the supine position with the abdomen exposed. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.

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 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.

A client with constipation has been instructed to increase the intake of foods high in fluid. Which food(s) will the nurse include in the client's education? Select all that apply.

Watermelon Strawberries Cantaloupe Lettuce Cucumber

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

Whole wheat spaghetti and broccoli

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?

Yogurt and buttermilk

Which client is most likely to require interventions in order to maintain regular bowel patterns?

a client whose neuropathic pain requires multiple doses of opioids each day

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

Fissure

a linear break on the margin of the anus

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

a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest f. A patient who has paralytic ileus caused by surgery

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? a. A saline osmotic laxative b. A bulk-forming laxative c. Methylcellulose d. A stool softener

a. A saline osmotic laxative

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.

a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG 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 the 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.

a. Draw up 30 mL of saline solution into the syringe c. Place the tip of the syringe in the tube to gently insert saline solution 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

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 low-fiber diet several days before the test. b. Have the patient take bisacodyl 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.

a. Have the patient follow a low-fiber diet several days before the test

A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? a. Incontinence b. Constipation c. Electrolyte imbalances d. Infection

a. Incontinence

Hemorrhoids

abnormally distended rectal veins

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

Colostomy

an opening into the colon that permits feces to exit through the stoma

Stoma

artificial opening for waste excretion located on the body surface

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 metformin for type 2 diabetes mellitus 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

b. A patient who is taking metformin for type 2 diabetes mellitus e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

For which patient would a nurse expect the primary care provider to order colostomy irrigation? a. A patient with IBS b. A patient with a left-sided end colostomy in the sigmoid colon c. A patient with post-radiation damage to the bowel d. A patient with Crohn's disease

b. A patient with a left-sided end colostomy in the sigmoid colon

Occult blood

blood present in such minute quantities that it cannot be detected with the unassisted eye

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.

c. Have the patient rest for 30 minutes to see if the prolapse resolves

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? 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.

c. Lower the solution container and check the temperature and flow rate

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then 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 primary care provider. c. Stop the procedure, assess vital signs, and notify the primary care provider. d. Stop the procedure, wait 5 minutes, and then resume the procedure.

c. Stop the procedure, assess vital signs, and notify the primary care provider

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? a. The nurse administers a large volume of solution (500 to 1,000 mL) b. The nurse mixes milk and molasses in equal parts for an enema c. The nurse instructs the patient to retain the enema for at least 30 minutes d. The nurse administers the enema while the patient is sitting on the toilet

c. The nurse instructs the patient to retain the enema for at least 30 minutes

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

cecum

Fecal impaction

collection in the rectum of hardened feces that cannot be passed

A nurse prepares to assist a patient with a 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."

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."

A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? 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. Monitoring bowel movements

d. Monitoring bowel movements

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider 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

d. b, a, d, c

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

dark pink and moist

Edoscopy

direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)

A client admitted with cellulitis of the leg has been prescribed amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy, the client develops severe diarrhea, and the nurse notifies the health care provider. The nurse would anticipate which course of action in response to the client's diarrhea?

discontinuation of the amoxicillin and the administration of a different antibiotic

Flatulence

excessive formation of gases in the gastrointestinal tract

Stool

excreted feces

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

Valsalva maneuver

forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure

Ostomy

general term referring to an artificial opening; usually used to refer to an opening created for the excretion of body wastes

Flatus

intestinal gas

Feces

intestinal waste products

Enema

introduction of solution into the lower bowel

Fecal incontinence

involuntary or inappropriate passing of stool or flatus

Peristalsis

involuntary, progressive, wave-like movement of the musculature of the gastrointestinal tract

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

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.

Incontinence-associated dermatitis

moisture-associated skin breakdown caused by prolonged contact of the skin with urine or feces

Suppository

oval- or cone-shaped substance that is inserted into a body cavity and that melts at body temperature

Paralytic ileus

paralysis of intestinal peristalsis

Constipation

passage of dry, hard fecal material

Diarrhea

passage of liquid and unformed stools

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.

Bowel-training program

program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas

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

skin turgor response 5 seconds