Ch.38 Bowel Elimination

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.

The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days.

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

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

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

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

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

auscultation.

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?

briefly clamping the tubing while the client breathes deeply

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema

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

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination

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

hyperactive bowel sounds

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

inadequate intake of liquid

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?

large-volume cleansing enema with hypotonic solution

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

left lateral

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?

mineral oil

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

oil

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

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

peptic ulcer

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:

physiologic or lifestyle changes in the client.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk for injury?

Wearing disposable gloves

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

Whole wheat spaghetti and broccoli

The nurse is caring for a client on bed rest who has constipation. How will the nurse document this finding?

primary constipation

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?

removes hardened fecal impactions from the rectum

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

secondary constipation

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

sigmoid colostomy

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

sims

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

skin turgor response 5 seconds

A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation?

tap water and normal saline solution

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse recognize the client will need?

vitamin B12

A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.

weak abdominal muscles severe dehydration unrelieved constipation

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds."

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

The nurse 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 they feel dizzy. What should the nurse educate the client about this condition?

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

The nurse is reviewing prescriptions to irrigate an ostomy. Which clients can have their ostomy irrigated? Select all that apply.

A client with a left-sided end colostomy A client with a sigmoid colostomy

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 nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes.

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.

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C 3 days before testing?

Avoid more than 250 mg.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing the tube, discontinue suction and separate the tube from suction.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

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

A paraplegic man receives care in the rehabilitation facility. He confides in a nurse that he has trouble controlling his bowel movements. He tends to normally stool 6 to 8 times per day. This has caused the skin around his rectum to become irritated. Which is not an appropriate NANDA-I diagnosis for this client?

Diarrhea r/t decreased muscle tone and sphincter control

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

The nurse is caring for four clients with diarrhea. When reviewing the client's chart, the nurse would contact the health care provider if which client has a prescription for an antidiarrheal agent?

Client with food poisoning

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

A client is reporting increased flatulence whichi is causing great embarrassement. When creating a plan of care for this client, what interventions will be most helpful to the client to control the excess flatulence. Select all that apply.

Encourage the client to limit the intake of carbonated beverages. Provide smoking cessation education and literature Encourage the client to avoid the use of straws when drinking liquid Inform the client that eating slowly and chewing food well can reduce the incidence of flautlence

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?

Ensure that the client fasts 6 to 12 hours before the test as per policy.

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.

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?

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

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply.

Help the client into a Sims' position. Compress the container as the solution instills. Encourage the client to retain the solution.

Which principle should guide the nurse's collection of a fecal occult blood test?

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

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

Inspection Auscultation Percussion Palpation

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?

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

The nurse is changing a client's ostomy appliance and observes that the peristomal skin is excoriated. What would be the nurse's priority intervention in this situation?

Make sure that the appliance is not cut too large.

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

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

Perform a screening test on stool samples.

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?

Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

Refrain from eating red meat 3 days before testing.

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

Sliced red apples

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway.

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

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

The proliferation of Clostridium difficile causes:

antibiotic associated diarrhea

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

Weakened pelvic muscles lead to constipation.

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable.

false

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?"

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)

The nurse is providing health teaching for four clients. Which client will the nurse teach that should consider a colonoscopy screening?

50-year-old client with a family history of polyps

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor?

The client takes bisacodyl every day.

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema?

draws fluid from body tissues into the bowel

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water.

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

brown rice

The nurse has provided a client with fecal immunochemical test (FIT) testing supplies. Which client statement reflects understanding of the purpose of this test?

"This test can help indicate if I have 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 test detects heme, an iron compound in blood within the stool."

The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply.

"Movement of the colon is stimulated by the parasympathetic nervous system." "The last part of the large intestine is the rectum, not the anus." "The stool becomes hard if it remains in the large intestine too long."

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

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

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.

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

False

The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply.

The autonomic nervous system innervates the muscles of the colon. Peristalsis occurs every 3 to 12 minutes. Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people. Mass peristalsis often occurs after food has been ingested.

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply.

The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The client should be instructed not to place toilet tissue in the bedpan or specimen container. Medical aseptic techniques are always followed. Handwashing is performed before and after glove use when handling a stool specimen.

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

The graduate places the client in Fowler's position.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?

The stoma is prolapsed.

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?

affects absorption of fat-soluble vitamins

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

cecum

The nurse is doing preoperative teaching with a client who has a prescription for GoLYTELY® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner?

chilled

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?

every 4 to 8 hours

Which medication causes constipation?

iron supplements