Chapter: 38 Bowel Elimination

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

brussels sprouts

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

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

dark pink and moist

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

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

fecal occult blood test, barium studies, endoscopic examination

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

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.

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

skin turgor response 5 seconds

A client has received nursing teaching about proper skin care at a stoma site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma?

water and mild soap

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

yellow.

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

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

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

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 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 bestaction?

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

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?

Auscultate for bowel sounds.

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.

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

Avoid more than 250 mg

A nurse 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

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

Cecum

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 asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

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

Which symptom is a known side effect of antibiotics?

Diarrhea

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

Digital removal of stool may cause parasympathetic stimulation.

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

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

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

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

A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?

Emptying a client's ileostomy appliance

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

Encourage physical activity to improve bowel regularity.

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 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.

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

Grapefruit

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

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.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

Which medication causes constipation?

Iron supplements

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.

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

Left lateral

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?

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

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 is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

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."

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

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

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

Sims

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

Sims

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.

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?

Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate

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.

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

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

The nurse is 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.

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.

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 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 has educated a client regarding an upcoming wireless video capsule endoscopy. What statement made by the client indicates that the client needs further education related to the procedure?

"The tablet will be absorbed and not excreted."

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

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

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 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.

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.

- 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

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?" - "Do you use laxatives?"

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

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.

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.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?

Use water and mild soap.

A 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.

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

Weakened pelvic muscles lead to constipation.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk

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