Chapter 39 - PrepU

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

A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? Select all that apply. cucumbers lentils shrimp pork products onions cabbage

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." Explanation: Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

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?

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?

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.

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

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.

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

diarrhea Explanation: A side effect of taking antibiotics such as clindamycin is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.

A client has been diagnosed with a dental infection and been prescribed a course of clindamycin. The nurse will monitor for what potential change in bowel function?

"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 occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

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.

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

cleansing enema Explanation: The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.

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?

"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.

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?"

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

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

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.

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?

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

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?

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.

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?

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.

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?

Attempt to irrigate the NG tube with water or normal saline. Explanation: An NG tube that is not draining should normally be irrigated. Turning the suction off and on is less likely to be effective, and it may be unsafe to leave the suction turned off for half an hour. Digestive enzymes are not used on NG tubes that are used for suction. Removing the NG tube would be an action of last resort.

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?

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

Mass lower left quadrant Distention Firmness Abdominal crepitus Rebound tenderness

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

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

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?

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

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure?

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

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

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 appreciable preventative measures for constipation.

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choice(s) 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

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

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

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 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

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 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?

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

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

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

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

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.

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?

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.

An older adult client often has uncontrolled passage of stool following a cerebrovascular accident. What nursing concern will the nurse include when planning this client's care?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins." Explanation: The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation.

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

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 indigestible, and this is unrelated to any changes in stomach pH.

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?

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.

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?

auscultation. Explanation: When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.

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:

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.

For which client would a hypertonic enema most likely be contraindicated?

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.

For which client would digital removal of stool be contraindicated?

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

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

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.

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?

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 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?

"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 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."

"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.

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?

"Certain vegetables can cause flatus, as they are more difficult to digest."

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?

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?

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 administering a large-volume enema to a client as prescribed. The client reports abdominal cramping. What should the nurse do first?

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 positions are not routinely used for this procedure.

The nurse is assisting an older adult client into position for a sigmoidoscopy. In which position will the nurse place the client?

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

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?

"Irrigating the colostomy can help establish an elimination routine." Explanation: Irrigations are used to promote regular evacuation of some colostomies. Left-sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate?

liquid stool Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes. Blood- or mucus-tinged stool is not expected, nor is stool of a formed consistency when exiting the gastrointestinal tract at this location.

The nurse is caring for a client with an ileostomy that was created 5 days ago. The nurse will teach the client to anticipate what type of expected ostomy output?

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

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

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

The nurse is creating a plan of care for an older adult client at risk for constipation. The nurse will provide what health education?

black clay colored yellow

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

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.

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

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

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

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. Meat and eggs are low in fiber. Fat in whole milk may be constipating.

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

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?

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 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."

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.

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?

Yogurt and buttermilk Explanation: Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.

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?

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.

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

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.

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?

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

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

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 nece

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.

"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.

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

"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.

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?

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

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

Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water. Explanation: Use of moist heat soothes the perineal area. Water is preferred because fluids with caffeine and sugars have a diuretic effect. When a client is using the bedpan, the head of the bed should be elevated to a minimum of 30 degrees. A low-fiber diet is recommended for a client with diarrhea. Clients require regular exercise to aid in defecation; once a week is not enough.

When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply. Elevate the bed to 15 degrees when using the bedpan. Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water. Encourage decreasing the amount of fiber in diet. Encourage the client to exercise once a week.

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

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

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.

When educating a breastfeeding parent on the characteristic of the stool of their newborn, the nurse will teach the parent to expect what stool characteristics?

client with anemia who is prescribed iron supplements Explanation: A common side effect of iron supplements is constipation. Aspirin, angiotensin-converting enzyme (ACE) inhibitors, diuretics and diabetes medications do not typically cause constipation.

Which client will the nurse monitor closely for signs and symptoms of constipation?

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.

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

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.

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

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

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

whether the client is taking new medication the client's normal bowel habits if the client feels a sensation of rectal fullness if the client has used laxatives in the past Explanation: The nurse will ask about new medications, because these can often cause constipation; what the client's normal bowel habits are like to establish a baseline; and whether the client has used laxatives to pass stool in the pass. A sensation of rectal fullness is associated with constipation. Loose stool is associated with diarrhea.

client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply. whether the client is taking new medication the client's normal bowel habits if the client feels a sensation of rectal fullness if the client has used laxatives in the past characteristics of loose stools