PrepU chapter 38 Bowel elimination

A parent brings a 2-year-old child 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." Which response by the nurse is appropriate? "You are putting too much pressure on yourself and your child to toilet train." "There may be something wrong since your child should be toilet trained by 2 years of age." "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." "Children vary in their readiness but daytime bowel control may be attained at 30 months."

"Children vary in their readiness but daytime bowel control may be attained at 30 months." Successful bowel training also includes awareness by the child of the need to defecate, the ability of the child to communicate this need, the child's wish to please the parent involved in bowel training, and the parent's praise and reinforcement for the child's successful behavior. Daytime bowel control is normally attained by 30 months of age, but the age varies with each child. Informing the parent that pressure is too much for the child may make the parent feel guilty and should be avoided. The nurse should never tell the parent that something is wrong if the child is not toilet trained, because this may vary with all children. The nurse is being dismissive when telling the parent that there is nothing to worry about.

When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client? "Do you drink lots of milk, but eat little meat?" "Do you frequently take antacids?" "Do you frequently consume red meats?" "Do you take any anticoagulants?" speckle: lm đốm

"Do you frequently take antacids?" Medications and food may affect the color of stools. Antacids may cause speckling or a white discoloration. Anticoagulants may cause the stools to be light pink to red to almost black. Consuming large quantities of red meats may cause the stool to be almost black. Stools are light brown when consuming large amounts of milk and milk products along with a diet low in meats.

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." "It depends on which testing developer is used." "Stool cannot be collect from a child's diaper." "Stool can be collected only from a cloth diaper."

"Only if the stool has not been contaminated by urine." Stool can be collected from a diaper for occult blood testing only if the stool has not been contaminated by urine. It does not matter whether the diaper is disposable or cloth. The type of developer does not make a difference as all are used to test for occult blood.

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 makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care." "The client uses spray deodorant several times an hour to mask odor." "The client is willing to look at the stoma." "The client agrees to take prescribed antidepressants."

"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." With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change.

The nurse has educated a client regarding an upcoming wireless video capsule endoscopy. What statement made by the client indicates that the client needs further education related to the procedure? "I will return after 8 hours to have the sensors and data recorder removed." "The capsule I have to swallow is no larger than a vitamin tablet." "I will be wearing a belt with the wires and a recorder." "The tablet will be absorbed and not excreted."

"The tablet will be absorbed and not excreted." The client swallows a capsule, about the size of a vitamin, which contains a small camera that emits a radio signal. Several wires on the client's abdomen pick up the radio signal from the capsule, and the data are recorded on a data recorder, which the client wears on a belt. The system captures about 55,000 images in an 8-hour exam. The client returns to the facility after 8 hours, and the external sensors and data recorder are removed. The capsule is excreted during the process of normal defecation in 24 to 48 hours and is intended for one-time use only

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." "This test will show if you have colorectal cancer." "This test will show if you have an infection in the bowel." "This test will determine whether foods are contributing to rectal bleeding."

"This test detects heme, a type of iron compound in blood in the stool." The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? 5 in (12.5 cm) 3 in (7.5 cm) 1 in (2.5 cm) 2 in (5.0 cm)

3 in (7.5 cm) The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? 50-year-old client with a family history of polyps 67-year-old client with constipation 33-year-old client who reports painful elimination 42-year-old client with diarrhea twice weekly

50-year-old client with a family history of polyps The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action? The appliance will fit securely to the client's skin. The appliance will need to be changed daily. A heightened risk that the stoma will prolapse A risk that the peristomal skin will become excoriated excoriated/ eks ko ri a^y dit/ bi tray

A risk that the peristomal skin will become excoriated An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer the solution gradually over 5 to 10 minutes. Warm the solution for 40 seconds in a microwave to prevent chilling the client. Administer analgesia 30 minutes before the procedure.

Administer the solution gradually over 5 to 10 minutes. Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client? Perform stoma irrigation. Apply device for stool collection. Have the client perform self stoma care Assess the color of the stoma.

Assess the color of the stoma. A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. If unable to irrigate the tube, remove it and obtain an order for replacement. Assist the client to a 30- to 45-degree position, unless this is contraindicated. If Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. i' ro* gate

Assist the client to a 30- to 45-degree position, unless this is contraindicated. 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 the syringe. If a 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.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? Consume citrus fruits Avoid more than 250 mg Take 500 mg Drink orange and grapefruit juice

Avoid more than 250 mg The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? Attach a syringe and flush with 50 mL of water or normal saline before removal. Place the client in a protective supine position to facilitate easy removal. Before removing the tube, discontinue suction and separate the tube from suction. Quickly and carefully remove tube while the client breathes out.

Before removing the tube, discontinue suction and separate the tube from suction. Explanation: When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? Position the bed flat and assist the client onto his or her left side. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. Administer an oral analgesia 30 to 45 minutes before attempting insertion.

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. To insert a nasointestinal tube, the nurse should measure the tube from the tip of nose to the earlobe and from the earlobe to the xiphoid process and add 8 to 10 in (20 to 25 cm) for intestinal placement. The client should be placed on his or her right side. Analgesia is not normally required in anticipation of placement.

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

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action? Discontinue the administration of the enema Clamp the tube for a brief period and resume at a slower rate. Continue infusing at a faster rate to finish the enema quicker. Remove the tubing.

Clamp the tube for a brief period and resume at a slower rate. Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

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. Refrigerate the specimen until it is cooled before sending it to the laboratory. If portions of the stool include visible blood, mucus, or pus, discard the stool. If the specimen contains barium or enema solution, document this on the container.

Collect 15 to 30 mL of the client's liquid stool. Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately.

A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply. Transporting the specimen Ordering the test Teaching the client about the test Planning medical treatment based on test results Handling the specimen Collecting the specimen

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test The nurse should follow facility protocol to collect, handle, and transport a specimen. It is very important to adhere to protocols and standards, collect the appropriate amount, use appropriate containers and media, and store and transfer the specimen within specified timelines. Client teaching is also an important part of specimen collection. The primary health care provider orders the test and plans medical treatment based on the results.

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

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. Explanation: Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. However, the body breaks down the other components of corn. Chewing corn for longer can also help the digestive system break down cellulose walls to access more of the nutrients. Sucrose, lactose, and galactose are sugars that are not fiber and more easily digestible by the body. During digestion, starches and sugars are broken down both mechanically (e.g. through chewing) and chemically (e.g. by enzymes) into the single units glucose, fructose, and/or galactose, which are absorbed into the blood stream and transported for use as energy throughout the body.

Which symptom is a known side effect of antibiotics? Constipation Fecal impaction Diarrhea Abdominal bloating

Diarrhea A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds. Allow the low intermittent suction to continue during the assessment of bowel sounds.

Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Explanation: If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

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? Advise decreasing dietary fiber in the diet to enhance stooling. Advise increasing milk or milk products in the diet to provide stool bulk. Suggest use of warm compresses on the abdomen to increase gastrointestinal motility. Encourage physical activity to improve bowel regularity.

Encourage physical activity to improve bowel regularity. Clients at risk for constipation should be encouraged to participate in regular physical activity to increase gastrointestinal motility and improve bowel regularity. Dietary fiber should be increased, not decreased. Milk products can result in constipation. Drinking water is important; however, the amount falls below the recommended amount of daily water intake.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? Peptic Ulcer Cirrhosis of the Liver Chronic Constipation Gastroesophageal Reflux Disease (GERD)

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

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? Provide a light meal before the test and administer two Fleet enemas. Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. Ensure that the client fasts 6 to 12 hours before the test as per policy. Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test.

Ensure that the client fasts 6 to 12 hours before the test as per policy. Explanation: The nurse would ensure that the client fasted 6 to 12 hours before the test as per policy. The nurse would not provide a light meal before the test, nor administer two Fleet enemas for an EGD. The client would not ingest a gallon of bowel cleanser. The nurse would not give the client a barium contrast mixture to drink.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube? Every 4 to 8 hours Every 1 to 2 hours Every 8 to 10 hours Nasogastric tubes should not be irrigated.

Every 4 to 8 hours Explanation: The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hour irrigated/ ia rờ gây đit/

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? Position the client on his side and administer a glycerin suppository. Facilitate a more private setting, such as assisting the client to a bathroom. Obtain a diet change order to increase the amount of fiber in the client's meals. Administer a normal saline enema after obtaining the relevant order.

Facilitate a more private setting, such as assisting the client to a bathroom. 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 hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. False True

False Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70 to 130 ml). These solutions draw water into the colon, which stimulates the defecation reflex. Oil retention enemas lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 ml of solution is administered to adults.

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. Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery. Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use.

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 preparing to administer an enema to a client who is constipated. Upon assessment, the nurse notes painful distended veins on the exterior rectum. Which action will the nurse take next? Use a different solution for the enema. Digitally stimulate the client to defecate. Generously lubricate the enema tube tip before proceeding. Continue with the enema with no further intervention.

Generously lubricate the enema tube tip before proceeding. Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. Hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Hemorrhoids can tear due to the firm enema tip; therefore, the enema tip should be generously lubricated and administered with caution to avoid tearing. Continuing as usual is inappropriate due to the hemorrhoid finding. Nurses do not digitally stimulate a client to void. The decision to change the enema solution is a health care provider order; therefore, the nurse cannot perform this option without speaking with the provider first.

A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding? Put on sterile gloves and gently reposition the stoma. Have the client rest for half an hour and then reassess. Irrigate the client's colostomy. Promptly notify the client's primary care provider.

Have the client rest for half an hour and then reassess. If the stoma is prolapsed, the nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to it. Irrigation and manipulation are not recommended responses to this situation.

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 the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. Replace the NG tube if the client experiences nausea within 6 hours of removal.

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.

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? Drink a soft drink daily to prevent gas and allow fiber to break down. Include more protein in the diet to increase fiber and decrease gas. Eat more cabbage and Brussel sprouts to decrease gas and add fiber. Increase fiber slowly over a period of time to prevent gas.

Increase fiber slowly over a period of time to prevent gas. Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.

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

Inspection Auscultation Percussion Palpation Explanation: When assessing a client's abdomen, the correct order for assessment is inspection, auscultation, percussion, and palpation.

Which medication causes constipation? Magnesium antacids Bisacodyl Aspirin Iron supplements

Iron supplements A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? Left lateral Semi-Fowler's Prone Right lateral

Left lateral The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

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? Modify the amount and length of the administration. Lower solution container and check temperature and flow rate. Remove the tube and check for any fecal contents. Place the client on bedpan in the supine position while receiving enema.

Lower solution container and check temperature and flow rate. The nurse's next action would be to lower the solution container and check the temperature and flow rate. Lowering the solution container decreases the pressure of the flow of the solution. The cramping could be related to the pressure of the flow, the temperature of the solution, or a high flow rate of the solution. The nurse would not place the client in a supine position, but in a low-Fowler's position or higher. The nurse would not remove the tube and check for any fecal contents. The nurse would not modify the amount and length of the administration, as this is not causing the severe cramping.

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 4 ounces of protein 3 times per day. Will include fish one to two times per week. Will includes a pat of butter with eggs for breakfast. Plans to eat a snack of fruit twice per day.

Plans to eat a snack of fruit twice per day. By snacking on fruits and vegetables, the client can increase fiber in the diet. The amount of fish, protein, and fat do not relate to increasing or absorbing fiber in the diet.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? Forced Expiratory Volume (FEV) Residual Volume (RV) Total lung capacity (TLC) Tidal volume (TV)

Residual Volume (RV) During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 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. Encourage the client to hold the solution for at least 20 minutes. Position the client on his back and drape properly. Introduce solution quickly over a period of 3 to 5 minutes.

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

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. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. Slow the infusion rate, have the client take deep breaths, then resume the enema. Stop the procedure and reposition the client. clammy skin da san sui

Stop the procedure, monitor heart rate and blood pressure. When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response.

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 curled in the back of the client's throat. The client is experiencing a vasovagal reaction. The client is forcefully resisting the procedure. The NG tube is in the client's airway.

The NG tube is in the client's airway. The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? The client consumes large quantities of fresh vegetables. The client returned from a foreign country 2 days ago. The client has a daily fluid intake of 2,000 to 3,000 ml. The client repeatedly ignores the urge to defecate.

The client returned from a foreign country 2 days ago. Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 ml of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.

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 placed the client in supine position with the abdomen exposed. The student had the client flex the knees when performing the assessment. The student instructed the client to urinate before beginning the focused assessment. The student sequenced from auscultation to inspection, and percussion to palpation.

The student sequenced from auscultation to inspection, and percussion to palpation. The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination.

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 barium studies, fecal occult blood test, endoscopic examination barium studies, endoscopic examination, fecal occult blood test endoscopic examination, barium studies, fecal occult blood test

There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: 1. Fecal occult blood test, 2. barium studies, and then 3. endoscopic examination.

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? Avoid using commercial skin preparations. Clean it with a dry, cotton bandage. Avoid applying a barrier substance. Wash it with a mild cleanser and water.

Wash it with a mild cleanser and water. Washing the stoma and surrounding skin with a mild cleanser and water, and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering.

Which factor is related to developmental changes in bowel habits for older adult clients? Increase in dietary fiber can decrease peristalsis. Milk products cause constipation in clients with lactose intolerance. Older adults should peel fruits before eating. Weakened pelvic muscles lead to constipation.

Weakened pelvic muscles lead to constipation. 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.

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? Onions and garlic Yogurt and buttermilk Asparagus and turnip Fish and dried lentils

Yogurt and buttermilk Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. /dē-ˈō-də-ˌrīz/ Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.

When assessing an older adult client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation? develops healthier bowel elimination patterns causes periodic bleeding and tissue trauma reduces elasticity in intestinal walls and slows motility affects absorption of fat-soluble vitamins

affects absorption of fat-soluble vitamins Older adult clients who use mineral oil to prevent or relieve constipation need to be informed that prolonged use affects the absorption of fat-soluble vitamins such as A, D, E, and K. Bleeding and tissue trauma does not occur due to use of mineral oil for constipation but during the digital removal of faction. Use of mineral oil for constipation does not develop healthier bowel elimination patterns, but the use of bulk-forming products containing psyllium or polycarbophil does. Loss of elasticity in intestinal walls and slower motility is due to old age, not the use of mineral oil.

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. Eat more cabbage and Brussel sprouts to decrease gas and add fiber. Include more protein in the diet to increase fiber and decrease gas. Drink a soft drink daily to prevent gas and allow fiber to break down.

age 50 and older a positive family history a history of inflammatory bowel disease The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals.

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

age 50 and older a positive family history a history of inflammatory bowel disease The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals.

The proliferation of Clostridium difficile causes: anal yeast infection. Escherichia coli diarrhea. antibiotic-associated diarrhea. Urinary Clostridium infection.

antibiotic-associated diarrhea. Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea. R

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: deep palpation. light palpation. auscultation. percussion.

auscultation. 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 is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. dark brown clay colored black yellow light brown

black clay colored yellow the nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.

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

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

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? tap water mineral oil hypertonic saline water, soap

hypertonic saline The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? soap and water tap water hypertonic saline mineral oil

hypertonic saline The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in the correct order. Use all options.

note the goal for inhalation exhale normally seal the lips around the mouthpiece inhale slowly until reach desired volume hold breath for 4 seconds remove mouthpiece and breathe normally

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 soap water normal saline

oil Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.

A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? Select all that apply. pork products onions shrimp cabbage cucumbers lentils flatulence /fla' cho*` lo*`n/

onions cabbage cucumbers lentils cucumbers, lentils, onions, and cabbage are known to produce gas; therefore, this client should avoid these foods. Shrimp and pork products are not associated with formation of gas.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? inspection palpation percussion auscultation

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

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: social and emotional setting of the client. drinking and smoking habits of the client. physiologic or lifestyle changes in the client. nature and amount of food eaten by the client.

physiologic or lifestyle changes in the client. Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence.

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? increases the volume of the stool, making defecation easier softens and facilitates the removal of intestinal polyps removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit

removes hardened fecal impactions from the rectum Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? temperature 99.9°F (37.9°C) heart rate 90 beats/min skin turgor response 5 seconds blood pressure 130/80 mm Hg

skin turgor response 5 seconds Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. Other assessment findings are normal.

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider? the client who develops dizziness and diaphoresis during administration the client who has a visual nonbleeding hemorrhoid the client who has an increase in bowel sounds after administration the client who experiences severe abdominal pain

the client who experiences severe abdominal pain Be gentle and lubricate the tip generously before insertion of the enema, but a hemorrhoid is not a reason to stop. When a client experiences dizziness, light-headedness, and sweating, the nurse should slow down the administration of the enema and ask the client to take slow, deep breaths and relax to decrease the symptoms of rapid administration and vagal response. The nurse should stop the enemas with severe abdominal pain, assess bowel sounds, and call the primary care provider because the pain may be a warning sign of trauma to the GI tract or potential perforation of the bowel. It is an expected finding that the enema will stimulate peristalsis.

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be: yellow. brown. green. beige.

yellow. If newborns are fed breast milk, the stools will be yellow to gold in color, soft, and unformed with an unobjectionable odor. Dark greenish stool characterizes the first stool after birth, the meconium. Beige and brown stools are characteristic of formula-feed infants.