TLB-Chapter 38: Bowel Elimination

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply. "How often do you go out to eat?" "Do you use anything to help move your bowels?" "How often do you move your bowels?" "Where do you do your grocery shopping?" "Do you prefer hot foods or cold foods?"

"Do you use anything to help move your bowels?" "How often do you move your bowels?" Explanation: To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination. Reference:

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 has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse? "Menstruation will not alter the test results. Go ahead with the test." "Wait to do the test 3 days after your finish menstruating." "As long as you wash the area and dry carefully, you can use the test." "If you are having a light flow or spotting then you can perform the test.

"Wait to do the test 3 days after your finish menstruating." Explanation: The client should be sure to postpone the test until 3 days after cessation of menstruation. If not, the client may experience a false-positive test.

In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet? 20-30 g 40-50 g 60-70 g >80g

20-30 g Explanation: A person who consumes approximately 20 to 30 grams of dietary fiber from fruits, vegetables, and grains will most likely have sufficient bulk in the stools to allow for easy defecation.

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.

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

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

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

A. lentils C. onions D. cabbage RATIONALE Lentils, onions, and cabbage are known to produce gas. Meats are generally not associated with formation of gas.

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? A. the client who has a visual nonbleeding hemorrhoid B. the client who develops dizziness and diaphoresis during administration C. the client who experiences severe abdominal pain D. the client who has an increase in bowel sounds after administration

C. the client who experiences severe abdominal pain RATIONALE 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.

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 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 8 to 10 hours Every 1 to 2 hours Nasogastric tubes should not be irrigated. Every 4 to 8 hours

Every 4 to 8 hours Explanation: The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

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 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 2Auscultation 3Percussion 4Palpation

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

A nurse is conducting an abdominal assessment. Which palpation finding(s) necessitates reporting to the health care provider? Select all that apply. Mass lower left quadrant Distention Firmness Abdominal crepitus Rebound tenderness

Mass lower left quadrant Distention Firmness Abdominal crepitus Rebound tenderness Explanation: All options are abnormal findings and should be reported to the health care provider.

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

antibiotic-associated diarrhea. Explanation: 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.

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.

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 providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply. hot tea with meals a turkey sandwich with whole-grain bread prune juice with breakfast ice cream with lunch and dinner diet soda with lemon

hot tea with meals a turkey sandwich with whole-grain bread prune juice with breakfast Explanation: A glass of prune juice is equivalent to more than one serving of the dried fruit, has high magnesium content, and is an excellent source of fluid to promote bowel elimination. Hot fluids, such as coffee, tea, or hot water with lemon juice, may also increase intestinal motility. High fiber foods such as whole-grain bread provide bulk for the stool. Ice cream and diet soda do not provide any preventative measures for constipation.

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

rect response: 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.

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.

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? "Stool cannot be collect from a child's diaper." "Stool can be collected only from a cloth diaper." "It depends on which testing developer is used." "Only if the stool has not been contaminated by urine."

"Only if the stool has not been contaminated by urine." Explanation: 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.

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces. True False

False Explanation: A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.

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.

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

Peptic Ulcer Explanation: 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.

A client is prescribed a large volume cleansing enema and is concerned as to why the large volume is indicated. What response should the nurse give to the client? Select all that apply. to relieve constipation to prevent involuntary escape of fecal material during surgical procedures to promote optimal visualization of the colon during a colonoscopy to promote optimal overall health by removing built-up toxins to assure a daily bowel movement

to relieve constipation to prevent involuntary escape of fecal material during surgical procedures to promote optimal visualization of the colon during a colonoscopy Explanation: Cleansing enemas are given to remove feces from the colon, commonly to relieve constipation or fecal impaction, prevent an involuntary escape of fecal material during surgical procedures, promote visualization of the intestinal tract by radiographic or instrument examination, and help establish regular bowel function during a bowel-training program. Cleansing enemas, as well as enemas in general, do not promote overall bowel health nor assure a daily bowel movement.

The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education? "I will need yearly screenings for colon cancer." "I will have a fecal occult blood test done every 5 years." "I will have a flexible endoscopic exam done every 5 years." "My mother had colon cancer so I am at a greater risk for also developing colon cancer."

"I will have a fecal occult blood test done every 5 years." Explanation: Yearly screenings, including a fecal occult blood test, should be done on all clients over the age of 50. A flexible endoscopic exam should be done every 5 years. A family history of colorectal cancer increases the risk of developing colorectal cancer.

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? A. Every 8 to 10 hours B. Every 1 to 2 hours C. Nasogastric tubes should not be irrigated. D. Every 4 to 8 hours

D. Every 4 to 8 hours RATIONALE The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

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

A. A risk that the peristomal skin will become excoriated RATIONALE 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.

Which statement about ostomy irrigation is true? A. For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. B. Daily irrigation is necessary to assure passage of stool from an ileostomy. C. Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. D. Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery.

A. For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. RATIONALE 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.

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.

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. Observe 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.

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply. A. Have the client lie on his stomach and pie-fold top linens over him. B. Place the client in a side-lying position. C. Vigorously work the finger around and into the hardened mass to break it up. D. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. E. Use a cleansing enema if necessary. F. Provide a sitz bath or tub bath after the procedure to soothe the perianal area

B. Place the client in a side-lying position. D. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. F. Provide a sitz bath or tub bath after the procedure to soothe the perianal area RATIONALE The nurse would have the client in a side-lying position. The nurse would use nonsterile gloves for the procedure because the intestinal tract is not sterile. The nurse would lubricate the index finger generously to reduce irritating the rectum, and insert the finger gently into the anal canal. The nurse would not have the client lie on the stomach. The nurse would use a gentle action, not a vigorous one, to break up the hardened mass of stool. The nurse would not use an enema unless it was ordered by the health care provider.

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 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.

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

D. Clamp the tube for a brief period and resume at a slower rate. RATIONALE 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 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? A. Place the client on bedpan in the supine position while receiving enema. B. Remove the tube and check for any fecal contents. C. Modify the amount and length of the administration. D. Lower solution container and check temperature and flow rate.

D. Lower solution container and check temperature and flow rate. RATIONALE 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 cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? A. mineral oil B. tap water C. soap and water D. hypertonic saline

D. hypertonic saline RATIONALE 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.

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

Facilitate a more private setting, such as assisting the client to a bathroom. Explanation: 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.

The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? Bacon Eggs Whole milk Grapefruit

Grapefruit Explanation: Constipation may be avoided, minimized, or eliminated with proper food selection. Citrus fruits, such as grapefruit, are good choices for a client with constipation as they are rich in soluble fiber pectin, which increases gastrointestinal motility. Bacon contains high fat, which increases constipation. Eggs are low in fiber and high in fat, which slows gastrointestinal motility. Fat in whole milk is constipating.

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. Promptly notify the client's primary care provider. Irrigate the client's colostomy. Have the client rest for half an hour and then reassess.

Have the client rest for half an hour and then reassess. Explanation: 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.

The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply. Put on sterile gloves. Insert gloved finger gently into anal canal, pointing toward the umbilicus. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

Insert gloved finger gently into anal canal, pointing toward the umbilicus. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Explanation: Steps in the process of digitally removing stool include the following: generously lubricating index finger of dominant hand with water-soluble lubricant; inserting gloved finger gently into anal canal, pointing toward the umbilicus; gently working the finger around and into the hardened mass to break it up; removing pieces of it and instructing client to bear down, if possible, while extracting feces to ease in removal. It is not necessary to put on sterile gloves, because this is not a sterile procedure. Clean gloves are sufficient for this procedure, so use of sterile gloves is not indicated.

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.

A client diagnosed with colorectal cancer reports constipation to the nurse. Which teaching will the nurse provide to help the client identify sign(s) or symptom(s) of constipation? Select all that apply. Watch for liquid bowel movements after days with none. Your abdomen will feel empty. You will urinate less often or not at all. You may experience pain on defecation. You will feel less thirsty.

Watch for liquid bowel movements after days with none. You will urinate less often or not at all. You may experience pain on defecation. Explanation: Constipation is accompanied by various signs and symptoms, such as pain on defecation, abdominal distention, and changes in the characteristics of stool, such as oozing liquid stool or hard, small stool. A person who is constipated does not report increased bowel movement frequency but a decreased frequency of bowel movements. Clients may report abdominal fullness or bloating and an inability to pass stool, not urine. Constipation will not cause the client to be less thirsty.

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.

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.

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

hypertonic saline Explanation: 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.

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.

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

orrect 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.

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 removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps

removes hardened fecal impactions from the rectum Explanation: 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.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? Remove the tubing 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.

rrect response: Lower the solution container and check the temperature and flow rate. Explanation: If the client experiences 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. A client should not be placed on a bedpan until after the rectal tube is removed. The rectal tube does not need to re-positioned or removed.

When assessing an elderly 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

rrect response: affects absorption of fat-soluble vitamins Explanation: Elderly 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.