Taylor's PrepU (Fundamental) Ch. 39 Bowel Elimination

The nurse is providing education for a client with frequent constipation about the use of bisacodyl to improve defecation. What statements made by the client indicate that the teaching is effective? Select all that apply. "Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." "This will help add bulk to my stools to ease defecation." "It will improve defecation by increasing motility." "I should increase my fluid intake to help with my bowel movements. "This will help soften the stool but won't stimulate motility."

"Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." "It will improve defecation by increasing motility." "I should increase my fluid intake to help with my bowel movements. Explanation: Stimulant laxatives, such as bisacodyl and senna, improve defecation by increasing motility through irritation of the intestinal mucosa and increased water in the stool. Bulk-forming laxatives such as psyllium hydrophilic mucilloid work by absorbing water into the intestine to soften the stool and increasing stool bulk, but bisacodyl is not considered a bulk forming laxative. Bisacodyl is not a stool softener.

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? "Certain vegetables can cause flatus, as they are more difficult to digest." "Parasites in your stool can cause persistent flatus." "Drinking alcoholic beverages can cause flatus." "Flatus is a natural action and the cause is unknown."

"Certain vegetables can cause flatus, as they are more difficult to digest." Explanation: Flatus is gas in or from the stomach or intestines that is passed through the anus. Foods that contain high amounts of fiber, such as vegetables, commonly produce flatus due to being harder to digest. Flatus is not likely related to a parasitic infection or drinking alcoholic beverages.

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 take any anticoagulants?" "Do you frequently consume red meats?" "Do you frequently take antacids?" "Do you drink lots of milk, but eat little meat?"

"Do you frequently take antacids?" Explanation: 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.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply. "Have you started a new medication?" "What are your normal bowel habits?" "Are you experiencing rectal fullness?" "Do you use laxatives?" "Is the stool difficult to pass?"

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?" Explanation: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

The nurse is conducting teaching with a client who has a prescription for a wireless capsule endoscopy. Which statement by the client would indicate to the nurse that the teaching was effective? "I will not be allowed to eat anything after the first 4 hours of the study." "I can go about my daily routine while the camera is passing though my small intestine." "I will feel bloated and uncomfortable because of the air used to expand my small intestine." "I will return 24 to 48 hours after swallowing the capsule to have the capsule removed."

"I can go about my daily routine while the camera is passing though my small intestine." Explanation: While the camera is passing through the small intestine, the client may resume normal activities. The client can have a small meal after the first 2 hours of the study. No air is used to expand the small intestine, so the client should not feel bloated and uncomfortable. The capsule will be excreted 24 to 48 hours after ingestion via normal defecation process.

The nurse is caring for a client who has orders to receive a hypertonic enema. The client asks what is going to happen during the procedure. Which response by the nurse is appropriate? "I will keep you covered as much as possible during the procedure." "You will need to lay completely on your stomach." "Do not try to hold the enema in; it will cause pain." "Lay flat on your back with your knees pulled to your chest."

"I will keep you covered as much as possible during the procedure." Explanation: Administration of medications using the rectal route can be embarrassing for the client; it is essential to provide for client privacy. The proper client positioning is the Sims position, not supine or prone. Enema solution should be retained as long as possible to help with the evacuation effect.

The nurse is performing a health history for a client who presents to the clinic with abdominal discomfort. Which statements made by the client indicate that the client is at risk for the development of constipation? Select all that apply "Sometimes I don't have the opportunity to defecate when I need to while I am at work." "I drink about 16 ounces of fluids a day." "I don't like to exercise because I am tired all of the time." "I eat foods high in fiber every day." "I do not regularly take laxatives."

"Sometimes I don't have the opportunity to defecate when I need to while I am at work." "I drink about 16 ounces of fluids a day." "I don't like to exercise because I am tired all of the time." Explanation: A client may be considered at risk for the development of constipation when he or she has insufficient fluid intake, when he or she delays having a bowel movement when the urge is present, and if there is inactivity. A client is also at risk for constipation if abusing laxatives or eating low-fiber foods as part of a daily diet. The use of high-fiber foods adds bulk to the stool and helps with passage of stool through the intestine.

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." "The client agrees to take prescribed antidepressants." "The client uses spray deodorant several times an hour to mask odor."

"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." Explanation: 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 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 happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid." "This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart." "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." "There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement."

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." Explanation: When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause the heart rate to slow and result in syncope in some clients.

The nurse has provided a client with supplies for a fecal immunochemical test (FIT). Which client statement reflects understanding of the purpose of this test? "This test can help indicate if I have colorectal cancer." "This test will indicate if I have a parasite in my stool." "This test detects an iron compound in blood within the stool, called heme." "This will determine what foods I am allergic to that affect digestion."

"This test can help indicate if I have colorectal cancer." Explanation: The client demonstrates understanding by stating that fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer. FIT does not test for allergic foods, nor does it test for parasites. The fecal occult blood test detects heme.

The nurse has provided a client with supplies for a fecal immunochemical test (FIT). Which client statement reflects understanding of the purpose of this test? "This test can help indicate if I have colorectal cancer." "This test will indicate if I have a parasite in my stool." "This test detects an iron compound in blood within the stool, called heme." "This will determine what foods I am allergic to that affect digestion."

"This test can help indicate if I have colorectal cancer." Explanation: The client demonstrates understanding by stating that fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer. FIT does not test for allergic foods, nor does it test for parasites. The fecal occult blood test detects heme.

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 will determine whether foods are contributing to rectal bleeding." "This test will show if you have colorectal cancer." "This test will show if you have an infection in the bowel." "This test detects heme, a type of iron compound in blood in the stool."

"This test detects heme, a type of iron compound in blood in the stool." Explanation: 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.

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 will determine what foods you are allergic to that affect digestion and elimination." "This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." "This test detects heme, an iron compound in blood within the stool." "This test will help determine whether you have an infectious process in the intestines."

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

A client has been given fecal immunochemical test (FIT) testing supplies. What teaching will the nurse provide about the purpose for this test? "This will determine what foods you are allergic to that affect digestion and elimination." "This test, if positive, will indicate bleeding in the lower gastrointestinal tract." "This test detects heme, an iron compound in blood within the stool." "This test will help determine whether you have an infectious process in the intestines."

"This test, if positive, will indicate bleeding in the lower gastrointestinal tract." Explanation: The fecal immunochemical test (FIT) uses antibodies directed against human hemoglobin to detect blood in the stool. A positive FIT is more specific for bleeding in the lower gastrointestinal tract . No drug restrictions are required for the FIT.

A client tells the nurse, "I increased my fiber, but I am still very constipated." Which information should the nurse share with the client about promoting bowel care? "Just give it a few more days and you should be fine." "Well, that should not happen. Let me recommend a good laxative for you." "When you increase fiber in your diet, you also need to increase liquids." "I will tell the health care provider you are having problems. Maybe the provider can help."

"When you increase fiber in your diet, you also need to increase liquids." Explanation: The nurse should caution the client to avoid increasing fiber intake without drinking enough fluids because this can lead to a bowel obstruction. 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. Consulting with the health care provider is not warranted. Suggesting a laxative is not important at current; more education is needed. Telling a client to wait a few more days is minimizing the issue.

The nurse is preparing to administer a hypertonic saline enema. How much should the nurse prepare to administer? 120 mL 180 mL 250 mL until the fluid runs clear

120 mL Explanation: A hypertonic saline enema should contain 120 mL of solution. Other answers are incorrect, as they represent too much fluid that could overly irritate local tissues and draw too much water into the bowel.

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? 3 in (7.5 cm) 1 in (2.5 cm) 2 in (5.0 cm) 5 in (12.5 cm)

3 in (7.5 cm) Explanation: 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? 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 67-year-old client with constipation

50-year-old client with a family history of polyps Explanation: 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.

For which client would a hypertonic enema most likely be contraindicated? A client who is severely constipated A client with renal impairment A client who has peripheral edema A client with type 1 diabetes

A client with renal impairment Explanation: Hypertonic solutions are contraindicated for clients with renal impairment or reduced renal clearance, because these clients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia. Diabetes, constipation, and edema do not necessarily contraindicate the safe and effective use of a hypertonic enema.

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? A risk that the peristomal skin will become excoriated The appliance will need to be changed daily. The appliance will fit securely to the client's skin. A heightened risk that the stoma will prolapse

A risk that the peristomal skin will become excoriated Explanation: 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? Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer analgesia 30 minutes before the procedure. Administer the solution gradually over 5 to 10 minutes.

Administer the solution gradually over 5 to 10 minutes. Explanation: 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.

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

Administer the solution gradually over 5 to 10 minutes. Explanation: 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.

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next? Apply skin barrier to the tip and end of the nose. Secure the tube to the client's nose using tape. Measure the length of the exposed tube. Lubricate the lips generously.

Apply skin barrier to the tip and end of the nose. Explanation: Skin barrier improves adhesion and protects the skin. Applying the skin barrier should occur before taping the tube to the client's nose, measuring the length of exposed tube, or lubricating the lips.

In the nursing care plan for an adult's prevention of constipation, the nurse should encourage what quantity of daily fiber intake? Approximately 25-34 g As much as the client can tolerate without bloating or diarrhea 5 - 15 g 80 -120 g

Approximately 25-34 g Explanation: The daily recommended consumption of approximately 25 to 34 g of dietary fiber from fruits, vegetables, and grains will promote intestinal regularity as well as overall health. Both excessive and inadequate fiber intake lead to disruption in bowel function.

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? Assess the color of the stoma. Apply device for stool collection. Perform stoma irrigation. Have the client perform self stoma care

Assess the color of the stoma. Explanation: 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? Assist the client to a 30- to 45-degree position, unless this is contraindicated. Draw up 60 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 blue air vent. 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. Explanation: 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.

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information? Measure abdominal girth. Ask when the client last had a bowel movement. Inspect the abdominal dressing. Auscultate for bowel sounds.

Auscultate for bowel sounds. Explanation: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention. Abdominal surgery places the client at risk for developing a paralytic ileus. The nurse would auscultate for bowel sounds, as absent bowel sounds 72 hours after abdominal surgery may signal that the client has developed a paralytic ileus. Measuring abdominal girth, asking about past bowel movements, and observing the dressing would not provide the needed information to determine if a paralytic ileus is occurring.

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

Avoid more than 250 mg Explanation: 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.

The nurse is teaching a client with diarrhea about dietary management. Which teaching will the nurse include? Select all that apply. Consume a full liquid diet for 12-24 hours. Choose bland foods, such as cottage cheese. Bananas and applesauce are appropriate. Red meats will decrease symptoms of nausea. Pasta with cream sauce will help coat the abdominal mucosa.

Choose bland foods, such as cottage cheese. Bananas and applesauce are appropriate. Explanation: The nurse will teach the client to consume a clear (not full) liquid diet for 12-24 hours; choose bland instead of rich foods, like bananas, applesauce, and cottage cheese; and refrain from foods such as red meat (which can be greasy) and cream sauce (too rich) during bouts of diarrhea.

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

Clamp the tube for a brief period and resume at a slower rate. Explanation: 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.

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

Clamp the tube for a brief period and resume at a slower rate. Explanation: 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 who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply. Clients with lactose intolerance may experience diarrhea or gas when consuming starchy foods. A client who is constipated should eat eggs and pasta to relieve the condition. Clients who are constipated should eat more fruits and vegetables. Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. Alcohol and coffee tend to have a constipating effect on clients. Clients with food intolerances may experience altered bowel elimination.

Clients who are constipated should eat more fruits and vegetables. Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. Clients with food intolerances may experience altered bowel elimination. Explanation: The nurse would realize that clients who are constipated should eat more fruits and vegetables. The nurse would realize that clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. The nurse would also realize that clients with food intolerances may experience altered bowel elimination. The nurse would realize that a constipated client would not eat eggs and pasta to relieve the constipation; a better choice would be fruits, vegetables, and increased fiber and fluids if not contraindicated. The nurse would realize that alcohol and coffee do not tend to have a constipating effect on clients.

A nurse is collecting a stool specimen of a client suspected of having Clostridioides difficile. Which guideline is recommended for this procedure? Collect 15 to 30 mL of the client's liquid stool. 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. Refrigerate the specimen until it is cooled before sending it to the laboratory.

Collect 15 to 30 mL of the client's liquid stool. Explanation: 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. Ordering the test Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test Planning medical treatment based on test results

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test Explanation: 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 cellulose, 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 lactose, 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.

A nurse is administering a client's large-volume enema. What assessment finding would indicate to the nurse that the solution is being administered too quickly? Decrease in heart rate Diaphoresis (sweating) and facial flushing Urge to defecate Rectal bleeding

Decrease in heart rate Explanation: Rapid administration of a large-volume enema can precipitate a vagal response, resulting in decreased heart rate. Diaphoresis and an urge to defecate may occur, but these are not likely the result of infusing the solution too quickly. Bleeding must be promptly addressed as it signals trauma to the intestinal mucosa. However, this is likely the result of insertion of the rectal tube, not rapid infusion of solution.

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. Nurses find the procedure distasteful and difficult to perform. Most clients will not consent to have digital removal of stool. It often causes rebound diarrhea and electrolyte loss.

Digital removal of stool may cause parasympathetic stimulation. Explanation: The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

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. Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to 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 preparing to carry out a fecal disimpaction of a client who has not had a bowel movement in 10 days. Which step(s) will the nurse include in this intervention? Select all that apply. Assist the client into a probe position on the bed. Don clean examination gloves after completing hand hygiene. Ask visitors to leave the client's room and pull the privacy curtain. Place a disposable pad under the client and cover the client with a drape. Insert a lubricated finger into the rectum and make vigorous movements to break the mass.

Don clean examination gloves after completing hand hygiene. Ask visitors to leave the client's room and pull the privacy curtain. Place a disposable pad under the client and cover the client with a drape. Explanation: Hand hygiene reduces the transmission of microorganisms. Donning clean examination gloves complies with standard precautions by providing a barrier between the hands and a substance that contains body fluid. Privacy demonstrates respect for the client's dignity. The disposable pad and drape prevent the soiling of the client and bed linens. When caring for a fecal disimpaction, the nurse will position the client in the Sims position. This lateral position facilitates access to the rectum and promotes client comfort. While it is correct that the nurse will insert a lubricated finger into the rectum, finger movements to break up the fecal mass should be gentle and slow. Vigorous movements will cause the client discomfort and risk-causing injury to the client.

A nurse is caring for older adult clients in an assisted living facility. The nurse encourages the clients to eat diets that are high in fiber to prevent constipation. In which way would the nurse assist the clients to plan a menu to ensure that their dietary intake is rich in fiber? Plan meals high in carbohydrates. Include fish and shellfish in the diet. Eat fruits and vegetables daily. Increase the amount of dairy in the diet.

Eat fruits and vegetables daily. Explanation: Constipation is often a chronic problem for older adults and a diet high in fiber is recommended. Fruits and vegetables are high in fiber and should be consumed daily. Dairy, cheese, and fish are not high in fiber and will not help prevent constipation. Adding carbohydrates is an important part of a healthy diet, but typically, carbohydrates are not high in fiber.

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

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Explanation: For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance. 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? Generously lubricate the enema tube tip before proceeding. Continue with the enema with no further intervention. Digitally stimulate the client to defecate. Use a different solution for the enema.

Generously lubricate the enema tube tip before proceeding. Explanation: 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 is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure? Position the client supine, as dictated by client comfort and condition. Insert generously lubricated finger gently into the anal canal, pointing away from 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 not to bear down while extracting feces in order to prevent vagal response.

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Explanation: 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.

Which principle should guide the nurse's collection of a fecal occult blood test? The nurse must assess the client's food and medication intake for the 2 weeks prior to the test. If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Recent use of over-the-counter stool softeners can cause a false-positive result. The results of the test will preliminarily indicate the site of a client's bleeding

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Explanation: In a woman who is menstruating, the test should be postponed until 3 days after her period has ended. Before stool testing, the client should avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results; there is no need to assess for a 2-week window. Stool softeners do not confound the results of testing. Results indicate the presence of blood, but not its source.

Which principle should guide the nurse's collection of a fecal occult blood test? The nurse must assess the client's food and medication intake for the 2 weeks prior to the test. If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Recent use of over-the-counter stool softeners can cause a false-positive result. The results of the test will preliminarily indicate the site of a client's bleeding.

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Explanation: In a woman who is menstruating, the test should be postponed until 3 days after her period has ended. Before stool testing, the client should avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results; there is no need to assess for a 2-week window. Stool softeners do not confound the results of testing. Results indicate the presence of blood, but not its source.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide? Avoid acetaminophen 7 days prior to testing. Drink orange juice to stay hydrated through the testing process. If you have had a recent nose bleed, postpone using test. If you have irritated hemorrhoids, this will not alter the results.

If you have had a recent nose bleed, postpone using test. Explanation: When educating a client about using the at home fecal occult blood test (FOBT), the nurse instructs the client to not use laxatives or enemas, postpone if female is menstruating, postpone if hematuria, bleeding hemorrhoids, or blood nose recently. Drinking orange juice can cause false negative results.

An older adult client often has uncontrolled passage of stool following a cerebrovascular accident. What will the nurse most likely include in the client's plan of care? Incontinent bowel related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence Retention of fecal matter related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

Incontinent bowel related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Explanation: The most appropriate nursing concern addresses the client's fecal incontinence, related to loss of sphincter control innervation. Diarrhea refers to the character of stool, not necessarily the loss of control. The client is not experiencing constipation.

A client with terminal cancer is taking high doses of an opioid for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care? Limit movement to decrease pain, which will promote elimination. Limit fluids during the evening hours. Administer opioids to encourage diarrhea. Increase fiber in the diet.

Increase fiber in the diet. Explanation: Opioid use decreases gastrointestinal motility, resulting in constipation. Bowel care strategies include increasing mobility, as well as fiber and fluid in the diet.

A nurse is caring for a client who has a large, hardened mass of stool that is interfering with defecation, making it impossible for the client to pass feces voluntarily. Which recommendation(s) will the nurse provide the client to prevent future fecal impaction from occurring? Select all that apply. Increasing fluid intake Increasing fat in the diet Limiting fluids after bedtime Requesting a laxative from the health care provider Increasing daytime exercise

Increasing fluid intake Increasing daytime exercise Explanation: The client has fecal impaction because the large, hardened mass of stool is interfering with defecation, making it difficult for the client to pass stool voluntarily. The client will need to prevent constipation by increasing fluid intake, exercising, and toileting at regular intervals. While laxatives can be effective in the short term, they can also cause dependence. Increasing fat in the diet will not help to prevent constipation. Limiting fluids after bedtime will help the client to not have the urge to urinate throughout the night.

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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Inspection 4Palpation 2Auscultation 3Percussion

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

The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client? Keep the client's bed in the lowest position. Encourage the client to eat fresh fruits and vegetables. If diarrhea is still present after 48 hours, continue giving diphenoxylate and atropine. Check with health care provider before giving diphenoxylate and atropine to a child.

Keep the client's bed in the lowest position. Explanation: Diphenoxylate and atropine may cause drowsiness, so the client is at risk for falls. The bed should be kept in its lowest position. Clients should avoid foods such as fresh fruits and vegetables as these foods are high in fiber; this client needs a low-fiber diet. Diphenoxylate and atropine should be discontinued if it has no effect on the diarrhea in 48 hours. Diphenoxylate and atropine do not contain aspirin, so the nurse need not check with the health care provider before administering.

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

Left lateral Explanation: 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.

A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation? Remove the tubing immediately and discontinue the procedure. Lower the solution container and check the temperature and flow rate. Place the client on a bedpan in the supine position while receiving the enema. Reposition the rectal tube and check for any fecal content.

Lower the solution container and check the temperature and flow rate. Explanation: If the client complains of severe cramping when the enema solution is introduced, 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. This assessment should precede removal of the tube or repositioning the client or the tube.

A nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer? Hypertonic Carminative Oil-retention Anthelmintic

Oil-retention Explanation: Oil-retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. A hypertonic enema draws water into the colon, which stimulates the defecation reflex. Carminative enemas help to expel flatus from the rectum and relieve distention secondary to flatus. Anthelmintic enemas are administered to destroy intestinal parasites.

A nurse is assessing the stoma of a client who had an ostomy. Which assessment finding(s) necessitates further evaluation of the stoma? Select all that apply. Pallor of the stoma Purple-blue color of the stoma Irritation and dryness at the stoma site Yellow discharge at the stoma site Bleeding at the stoma site

Pallor of the stoma Purple-blue color of the stoma Irritation and dryness at the stoma site Yellow discharge at the stoma site Bleeding at the stoma site Explanation: The normal ostomy stoma should be dark pink to red and moist. Abnormal findings that should necessitate further assessment of the stoma include paleness (possible anemia), purple-blue color (possible ischemia), bleeding, irritation and dryness, or a yellowish discharge, which could indicate infection.

The nurse is administering a large-volume enema to a client as prescribed. The client reports abdominal cramping. What should the nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the health care provider. Pause the administration of the enema momentarily. Gently increase the flow of the enema until all of the solution has been administered.

Pause the administration of the enema momentarily. Explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the health care provider.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Place the client in high Fowler's position. 4Direct the tube upward and backward along the floor of the nose. 2Measure the intended length to insert the NG tube. 5Instruct the client to place the chin onto the chest. 3Lubricate the tube tip with water-soluble lubricant. 6Advance the tube while the client swallows.

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows. Explanation: An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler's position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client's stomach. Lubrication reduces friction and facilitates passage of the tube into the stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.

A nurse attempts to administer a tap water enema to a client who is dehydrated and finds that the client cannot retain the enema for the prescribed amount of time. What nursing action would be appropriate for this client? Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the health care provider. Place the client in a sitting position on the toilet and lower the enema solution. Stop the enema and reposition the rectal tube or remove it to check for any fecal contents. Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.

Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. Explanation: If the client cannot retain the enema solution for an adequate amount of time, place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort. If still unable to retain the solution, notify the health care provider. The nurse does not need to reposition the rectal tube but needs to assist the client by repeating the procedure with a slight variation.

An older adult client has been diagnosed with Clostridium dfficile-related diarrhea. What aspect of the client's health history wil the nurse identify as the most likely contributing factor? Recent use of antibiotics Age-related changes to bowel motility Use of over-the-counter probiotics Concurrent yeast infection

Recent use of antibiotics Explanation: Normal intestinal flora inhibit the growth of Clostridioides 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. This is unrelated to age-related physiologica changes or yeast infections. Probiotics have the ability to mitigate this effect of antibiotics.

An older adult client has a history of constipation and currently self-treats with over-the-counter laxatives. What education will the nurse provide the client regarding the use of laxatives? Select all that apply. Rectal suppositories need to be retained in the rectum for at least 15 minutes. Oral laxatives take longer to work than laxatives administered rectally. All older adults should use laxatives to promote normal defecation. Older adults are at a higher risk for laxative misuse and abuse. Incorporate high-fiber foods into the diet and increase fluid intake.

Rectal suppositories need to be retained in the rectum for at least 15 minutes. Oral laxatives take longer to work than laxatives administered rectally. Older adults are at a higher risk for laxative misuse and abuse. Incorporate high-fiber foods into the diet and increase fluid intake. Explanation: When providing education to an older adult client regarding prevention and treatment of constipation, the nurse will include information about the length of time it can take oral laxatives to be effective compared with rectal suppositories. If the client has had a rectal suppository to treat constipation in the past, the client may expect that oral laxatives will work just as quickly. It is important for the nurse to make this distinction between the two routes of administration so the client does not become impatient, leading to overuse of laxatives. Laxative abuse is possible among older adult clients experiencing changes in bowel routine. Some older adult clients may become bowel-conscious and overuse laxatives or have sustained laxative abuse. Bowel assessment can discover these issues for appropriate intervention. It is important to inform the client that the suppository needs to stay in the rectum for at least 15 minutes to be adequately absorbed by the intestine. Premature expulsion will render the laxative ineffective. Lifestyle modifications have an effect on bowel regularity. The nurse will include health promotion recommendations when educating the older adult client about bowel health. Fiber and fluid intake along with physical activity are key lifestyle modifications to preventing constipation. The nurse will not emphasize that it is expected for older adult clients to use laxatives due to normal effects of aging. Lifestyle changes should always be the first intervention and can be highly effective for olde

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? prone supine semi-Fowler Sims

Sims Explanation: Sims position is appropriate for a client who will receive a hypertonic enema because it promotes gravity distribution of the solution. The other positions are incorrect for this procedure.

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? Scrambled eggs Steamed haddock Cream of wheat Sliced red apples

Sliced red apples Explanation: Fresh fruits are high in fiber and should be avoided in a low-fiber diet. Refined grains (cream of wheat), eggs, and fish (steamed haddock) are low in fiber.

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse will teach the mother to expect what stool characteristics? Very dark stools for the first 7 to 10 days Soft, yellow stools Brown, liquid stools Loose, light grey stools

Soft, yellow stools Explanation: 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. Very dark stools would be considered an anomaly.

The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed? Places a disposable pad on the work surface Empties the pouch before changing the appliance Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate Applies a skin protectant to a 2-in (5-cm) radius around the stoma and allows it to dry completely

Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate Explanation: When removing the appliance, the nurse should start at the top, not bottom, to prevent spillage of intestinal content. The disposal pad protects the work surface. Emptying the appliance before removal prevents spillage of fecal material. The skin should dry completely to provide good adherence of the appliance; applying a protectant to a 2-in (5-cm) radius around the stoma provides protection to the skin and prevents breakdown.

The nurse reviews information about defecation with a group of nursing students in preconference prior to their clinical experience for the day. What response by the students indicate that the information given by the nurse is understood? Defecation refers to the emptying of the small intestine. The center in the medulla and another center in the spinal cord govern the reflex to defecate. When stimulation of the sympathetic nervous system occurs, the internal anal sphincter relaxes and the colon contracts, sending fecal content to the rectum. Rectal distention leads to a decrease in the pressure in the rectum and this causes the muscles to stretch and thereby stimulate the defecation reflex.

The center in the medulla and another center in the spinal cord govern the reflex to defecate. Explanation: Two centers govern the reflex to defecate. One center is in the medulla, and a subsidiary center is in the spinal cord. Defecation refers to the emptying of the large intestine. When parasympathetic, not sympathetic, stimulation occurs, the internal anal sphincter relaxes and the colon contracts. Rectal distention leads to an increase in intrarectal pressure, causing the muscles to stretch and thereby stimulating the defecation reflex.

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor(s) will prevent the nurse from administering this type of enema? Select all that apply. The client has a history of chronic kidney injury. The client has an elevated glucose level. The client has an elevated phosphorus level. The client is lactose intolerant. The client has a history of left-sided heart failure.

The client has a history of chronic kidney injury. The client has an elevated phosphorus level. The client has a history of left-sided heart failure. Explanation: The administration of a hypertonic saline solution should be omitted in a client that has a history of left-sided heart failure, because the client will be at risk for fluid buildup. It is also contraindicated for clients with kidney impairment or reduced kidney clearance, because such clients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia. The client will be able to use a hypertonic solution if they have diabetes or are lactose intolerant.

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor? The client eats five to six small meals per day. The client traveled to South America two weeks ago. The client takes bisacodyl every day. The client drinks 8 glasses of fluid daily.

The client takes bisacodyl every day. Explanation: Habitual use of laxatives such as bisacodyl may cause of chronic constipation. Traveling to South America usually causes a client to develop traveler's diarrhea. Drinking eight glasses of fluid daily promotes bowel elimination. Consuming five to six small meals per day should not contribute to constipation.

A nurse prepares to collect a stool sample from a client to test for fecal fat. Which guideline accurately describes a consideration in this process? Discard a stool sample if the client is menstruating or has placed toilet paper into the commode with the stool. Redo a test if the specimen has been inadvertently left at room temperature instead of being sent to the laboratory. Do not collect a stool sample from an incontinence brief or diaper of a client. The entire amount of stool produced for 24 to 72 hours should be sent to the laboratory.

The entire amount of stool produced for 24 to 72 hours should be sent to the laboratory. Explanation: For a timed stool test, such as fecal fat, the entire amount of stool produced for 24 to 72 hours is sent to the laboratory. In the cases of a room temperature sample or the presence of toilet paper, the nurse should call the laboratory to discuss possible effects on test results. Stool can be collected from an incontinent brief or diaper as long as it has not been contaminated by urine.

A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply. Voluntary control of defecation occurs between the ages of 12 and 18 months. The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days. A child who has not had a bowel movement daily is most likely constipated. In an infant, a liquid stool signifies diarrhea.

The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days. Explanation: The nurse would note that the number of stools that infants pass varies greatly. The number of bowel movements is often related to the feeding the infant is receiving. Breastfed babies often have 2 to 10 stools a day, where formula-fed babies have 1 to 2 stools daily. The nurse would also note that some children have bowel movements only every 2 or 3 days. The nurse would note that constipation is often a chronic problem for older adults. The nurse knows that the voluntary control of defecation occurs between the ages of 18 to 24 months, not 12 to 18 months. A child is likely not constipated if they do not have a daily bowel movement. Children differ in their individual bowel patterns. Liquid stool does not always signify diarrhea in a child. Loose stools may be related to overfeeding.

The nurse caring for a client with a new colostomy. Which assessment finding would be considered abnormal and would need to be reported to the health care provider? The stoma is pink The stoma has a small amount of bleeding`` The stoma is prolapsed The stoma is on the abdominal surface

The stoma is prolapsed Explanation: If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal at first.

The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which interventions are appropriate suggestions? Select all that apply. Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. Apply a commercially available skin barrier before applying the ostomy pouch. Secure the ostomy pouch in place by wrapping an elastic bandage around the abdomen, making sure to cover the entire ostomy appliance. Leave the ostomy pouch off and cover the stoma with an adult incontinence pad. After applying the ostomy pouch, lie flat in the prone position for 10 to 15 minutes to facilitate adhesion.

Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. Apply a commercially available skin barrier before applying the ostomy pouch. Explanation: In cases in which a client's colostomy bag continues to come loose or fall off, the nurse should either perform or recommend that the client do the following: thoroughly cleanse the skin and apply skin barrier. Allow the area to dry completely. Reapply the pouch. Monitor pouch adhesion and change the pouch as soon as there is an adhesion break. Wrapping an elastic bandage around the colostomy pouch would restrict the flow of feces into the pouch and should not be done. The ostomy pouch should not be left off and replaced with an adult incontinence pad, as this would result in leakage. Having the client lie flat in the prone position for 10 to 15 minutes after applying the pouch to facilitate adhesion is not necessary; the nurse simply needs to apply gentle, even pressure to the appliance for about 30 seconds after applying it.

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. 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. Explanation: 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. 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.

An older adult has developed occasional constipation despite having no such issues during their adult years. Which developmental factor is most likely related to this change? Increases in dietary fiber can decrease peristalsis Lactose intolerance can develop with age, causing constipation Weakened pelvic muscles lead to constipation. Increased stomach pH causes fiber to be indigestable

Weakened pelvic muscles lead to constipation. Explanation: 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. Fiber is always indigestable and this is unrelated to any changes in stomach pH.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk? Using a tongue depressor to access stool Taking sample directly from commode insert Wearing disposable gloves Not removing commode insert from commode

Wearing disposable gloves Explanation: The nurse is responsible for obtaining the specimen according to facility procedure, labeling the specimen, and ensuring that the specimen is collected safely and transported to the laboratory in a timely manner. Use of medical aseptic techniques is imperative. Always wear disposable gloves when any contact or handling of a stool specimen is likely. While all actions help prevent contact with the stool, and thus help minimize the risk for injury to the staff, the use of disposable gloves has the greatest impact by being a barrier against direct contamination of the skin by the stool itself.

A client with lactose intolerance is experiencing abdominal distress, gas, and diarrhea after breakfast each morning. After reviewing the client's food journal, which meal should the nurse point out as a potential trigger? Fried eggs and toast Peanut butter protein bar and black coffee Fruit and plain bagel Yogurt fruit smoothie

Yogurt fruit smoothie Explanation: A client with lactose intolerance should be advised to not drink milk or milk products, such as yogurt. All other answer options do not contain milk products.

For which client would digital removal of stool be contraindicated? a client recovering from prostate surgery a diabetic client with renal complications a client with a spinal cord injury a client with a urinary tract infection

a client recovering from prostate surgery Explanation: Digital removal of stool should not be performed on clients who have bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. None of the other listed health problems contraindicate digital removal of stool.

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 a diet lacking in glucose and water a diet lacking in refined grains, seeds, and nuts a diet lacking in meat and poultry products

a diet lacking in fruits and vegetables Explanation: 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 (not refined) grains, seeds, and nuts provide fiber, which helps in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.

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? reduces elasticity in intestinal walls and slows motility affects absorption of fat-soluble vitamins causes periodic bleeding and tissue trauma develops healthier bowel elimination patterns

affects absorption of fat-soluble vitamins Explanation: 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.

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 a diet high in fruits, vegetables, and whole grains.

age 50 and older a positive family history a history of inflammatory bowel disease Explanation: 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 nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. dark brown light brown black clay colored yellow

black clay colored yellow Explanation: 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: duodenum jejunum ileum cecum

cecum Explanation: 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 is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply. dark brown light brown black clay colored yellow

dark brown light brown Explanation: 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 nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema? promotes bowel movement without irritation effect lubricates and softens the stool draws fluid from body tissues into the bowel causes chemical irritation of the mucous membranes

draws fluid from body tissues into the bowel Explanation: A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply. lentils shrimp onions cabbage pork chops chicken nuggets

lentils onions cabbage Explanation: Lentils, onions, and cabbage are known to produce gas. Meats are generally not associated with formation of gas.

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? water soap normal saline oil

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

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

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding? primary constipation secondary constipation iatrogenic constipation pseudoconstipation

secondary constipation Explanation: The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? sigmoid colostomy ileostomy transverse colostomy ascending colostomy

sigmoid colostomy Explanation: Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as the site of the colostomy in the colon (preferably the sigmoid colostomy where constipation occurs) and the client's and health care provider's preferences, determine whether a colostomy is to be irrigated. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled. The transverse and ascending colon are located before the sigmoid area, which is closest to the rectum.

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

skin turgor response 5 seconds Explanation: 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.

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather? tap water mineral oil soap and water hypertonic saline

tap water Explanation: The nurse will gather tap water, which is used to distend the rectum and moisten stool. Mineral oil is used for a retention enema. Soap and water are used to irritate local tissue; hypertonic saline irritates local tissue and draws water into the bowel.

A client has just consumed a serving of ice cream and develops severe cramping and diarrhea. Which additional information will the nurse obtain to determine if the client has lactose intolerance? the client's vital signs what other symptoms the client is experiencing amount of fiber the client has ingested results of a stool sample test

what other symptoms the client is experiencing Explanation: 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. Assessing all client symptoms will help determine the cause of the symptoms. Assessing the vital signs, particularly the temperature, might lead the nurse to determine that the client possibly has food poisoning. Ingesting large amounts of foods high in fiber could lead to cramping and loose stools. Stool samples are tested for culture and sensitivity to determine if the client is experiencing an infection.