FON Chapter 38 Bowel Elimination

stoma:

artificial opening for waste excretion located on the body surface

constipation:

passage of dry, hard fecal material

diarrhea:

passage of liquid and unformed stools

The postpartum nurse is instructing a new mother that her infant will pass meconium for:

3 days Explanation: By the 3rd day after birth, the stool's characteristics begin to reflect the type of milk in the diet.

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?

"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.

stool:

excreted feces

anus:

opening at the end of anal canal

fissure:

a linear break on the margin of the anus

occult blood:

blood present in such minute quantities that it cannot be detected with the unassisted eye

bowel-training program:

program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas

bowel incontinence:

the inability of the anal sphincter to control the discharge of fecal and gaseous material

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." 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.

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." Explanation: The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This 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.

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

1. "Sometimes I don't have the opportunity to defecate when I need to while I am at work." 2. "I drink about 16 ounces of fluids a day." 3. "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 selecting antidiarrheal medications for clients with diarrhea. Which statements accurately describe the action of specific antidiarrheal medications? Select all that apply.

1. Loperamide is a nonaddictive antidiarrheal medication that has a longer duration of action than diphenoxylate/atropine. 2. Bismuth subsalicylate contains salicylates; a physician should be consulted before giving it to children or clients taking aspirin. 3. Paregoric contains morphine and may be addictive. Explanation: Loperamide is a nonaddictive antidiarrheal medication that has a longer duration of action than diphenoxylate/atropine. Bismuth subsalicylate contains salicylates; a physician should be consulted before giving it to children or clients taking aspirin. Paregoric contains morphine and may be addictive. Attapulgite interferes with the absorption of other oral medications. Loperamide is not an antimicrobial agent.

An older adult client immigrated from the Middle East and speaks very little English. The client reports blood in the stool but is treating it with a mixture of herbs imported from the client's home country. Which statements apply to this client? Select all that apply.

1. Treatment for bowel changes with folk remedies is a common practice. 2. The client may be reluctant to discuss bowel movements in front of a health care provider of the opposite sex. Explanation: Family members should never be substituted for a medical interpreter. Use of an interpreter who is of the same age and gender may be helpful in this situation. The presence of blood in the stool is always of concern and must be addressed that day.

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.

1. hot tea with meals 2. a turkey sandwich with whole-grain bread 3. 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.

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) Explanation: The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.

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

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.

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest c. A patient who has diarrhea d. A patient who has gastroenteritis e. A patient who has an early bowel obstruction f. A patient who has paralytic ileus caused by surgery

a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Hogan-Quigley, Palm, & Bickley, 2017)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. a. Draw up 30 mL of saline solution into the syringe. b. Unclamp the suction tubing near the connection site to instill solution. c. Place the tip of the syringe in the tube to gently insert saline solution. d. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. e. After instilling irrigant, hold the end of the NG tube over an irrigation tray. f. Observe for return flow of NG drainage into an available container.

a, c, e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? a. A saline osmotic laxative b. A bulk-forming laxative c. Methylcellulose d. A stool softener

a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a. Have the patient follow a low-fiber diet several days before the test. b. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. c. Prepare the patient for the use of general anesthesia during the test. d. Explain that barium contrast mixture will be given to drink before the test.

a. If possible, a low-residue diet (low fiber) should be followed several days before the procedure. Most will maintain the low-residue diet; others may have full liquid diet the day before the procedure. There are multiple types of bowel preps for this procedure. The provider performing the procedure will decide which is best for the individual patient. The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. It is recommended the second dose be given at least 5 hours and completed at least 2 hours before the study. There are some who may receive the prep the same day as the procedure, especially if the procedure is scheduled for later in the day. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests.

A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? a. Incontinence b. Constipation c. Electrolyte imbalances d. Infection

a. The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. A patient who is taking narcotics for pain b. A patient who is taking metformin for type 2 diabetes mellitus c. A patient who is taking diuretics d. A patient who is dehydrated e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

For which patient would a nurse expect the primary care provider to order colostomy irrigation? a. A patient with IBS b. A patient with a left-sided end colostomy in the sigmoid colon c. A patient with post-radiation damage to the bowel d. A patient with Crohn's disease

b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn's disease (Kent et al., 2015).

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? a. Elevate the head of the bed 30 degrees and reposition the rectal tube. b. Place the patient in a supine position and modify the amount of solution. c. Lower the solution container and check the temperature and flow rate. d. Remove the rectal tube and notify the primary care provider.

c. If the patient reports severe cramping with introduction of an enema solution, 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. The head of the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a. Reassure the patient that this is a normal finding with a new ostomy. b. Notify the primary care provider that the stoma is prolapsed. c. Have the patient rest for 30 minutes to see if the prolapse resolves. d. Remove the appliance and redo the procedure using a larger appliance.

c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. 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 the stoma.

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? a. The nurse administers a large volume of solution (500 to 1,000 mL) b. The nurse mixes milk and molasses in equal parts for an enema c. The nurse instructs the patient to retain the enema for at least 30 minutes d. The nurse administers the enema while the patient is sitting on the toilet

c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse's next action? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the primary care provider. c. Stop the procedure, assess vital signs, and notify the primary care provider. d. Stop the procedure, wait 5 minutes, and then resume the procedure.

c. When a patient reports dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the health care provider. The vagus nerve may have been stimulated.

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark-green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages."

d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark-green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a. c, b, d, a b. d, c, a, b c. a, b, d, c d. b, a, d, c

d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1,000 mL c. Administering an enema once a day to stimulate peristalsis d. Monitoring bowel movements

d. For a bowel-training program to be effective, the nurse should monitor bowel movements including frequency, consistency, shape, volume and color, as appropriate, monitor bowel sounds, teach patient about specific foods that are assistive in promoting bowel regularity, ensure privacy, and encourage adequate fluid intake.

laxative:

drug used to induce emptying of the intestinal tract

Valsalva maneuver:

forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure

ostomy:

general term referring to an artificial opening; usually used to refer to an opening created for the excretion of body wastes

peristalsis:

involuntary, progressive, wave-like movement of the musculature of the gastrointestinal tract

incontinence-associated dermatitis:

moisture-associated skin breakdown caused by prolonged contact of the skin with urine or feces

suppository:

oval- or cone-shaped substance that is inserted into a body cavity and that melts at body temperature

paralytic ileus:

paralysis of intestinal peristalsis

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?" 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.

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." 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.

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." Explanation: The rectum is the last part of the large intestine. Water is absorbed while the stool is in the large intestine; therefore, the longer it remains there, the harder it becomes. The parasympathetic nervous system stimulates the colon. Vitamin K and some of the B-complex vitamins are produced by bacterial action in the large intestine. The nervous system innervates the muscles of the colon.

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." 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?

"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 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." Explanation: With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change.

The nurse is 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 Explanation: An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

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

Administer the solution gradually over 5 to 10 minutes. Explanation: Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent Explanation: Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Anti-flatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

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. Explanation: To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe. If a Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.

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. 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.

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. 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.

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 Explanation: The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

A nurse is irrigating a client's nasogastric tube. Place the following steps in the correct order. Use all options.

Check placement of the nasogastric tube. Draw up 30 mL of irrigation solution into a syringe. Clamp the nasogastric tube near the connection site. Hold the syringe upright, and gently insert the irrigant. Hold the end of the nasogastric tube over an emesis basin. Inject air into the blue air vent. Rationale: Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged. Drawing up the specified amount of solution into a syringe ensures delivery of the proper amount of irrigant through the tube. Clamping prevents leakage of gastric fluid. Gentle insertion of saline solution (or gravity insertion) is less traumatic to gastric mucosa. Return flow may be collected in an irrigating tray or other available container and measured. This amount needs to be subtracted from the irrigant to record the true nasogastric drainage. Following irrigation, the blue air vent is injected with air to keep it clear. Page 1465-1468

The nurse is teaching a client with diarrhea about dietary management. Which teaching will the nurse include? Select all that apply.

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

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

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. 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 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. 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 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. Explanation: Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. However, the body breaks down the other components of corn. Chewing corn for longer can also help the digestive system break down cellulose walls to access more of the nutrients. Sucrose, lactose, and galactose are sugars that are not fiber and more easily digestible by the body. During digestion, starches and sugars are broken down both mechanically (e.g. through chewing) and chemically (e.g. by enzymes) into the single units glucose, fructose, and/or galactose, which are absorbed into the blood stream and transported for use as energy throughout the body.

Which symptom is a known side effect of antibiotics?

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

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 Explanation: This client is not currently experiencing diarrhea. He does not describe his stools as watery or loose. Rather, this client's problem is with control of the bowel.

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. Explanation: If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do?

Document the output; this is normal. Explanation: Output from a colostomy is normally formed stool. Therefore the nurse should document the output as normal. There is no need to contact the physician at this time, assess for an obstruction, or give a laxative since the formed stool is normal.

What is meconium?

Dry intestinal secretions Explanation: Meconium is the partially dried intestinal secretions that accumulate in the large intestine before birth.

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 Explanation: It is safe for an experienced UAP to empty an ostomy. GI assessment and insertion and irrigation of an NG tube cannot be delegated.

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. 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.

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

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

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 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. 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 client with terminal cancer is taking high doses of a narcotic for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

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

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. 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.

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 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 client reports diarrhea and taking loperamide for 4 days. The client exhibits signs and symptoms of dehydration. What are appropriate actions of the nurse? Select all that apply.

Instruct the client to discontinue loperamide. Perform an abdominal assessment. Tell the client to increase ingestion of water, broth, clear soups, and gelatin. Explanation: The nurse would complete an assessment of a client who reports diarrhea and taking an antidiarrheal medication. The assessment would include an abdominal examination to assist in determining the cause of the diarrhea. The nurse would instruct the client to discontinue loperamide. This medication is to be taken only for 48 hours, not 4 days. The nurse would also instruct the client to increase fluids to avoid and treat dehydration. Fluids would be water, broth, clear soups, and gelatin. The nurse would instruct the client to avoid eating raw fruits and vegetables. The nurse would not teach about the BRAT diet, because this diet lacks sufficient calories.

Which medication causes constipation?

Iron supplements Explanation: A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.

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

Left lateral Explanation: The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

A nurse 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?

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

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

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

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. 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.

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. Explanation: The nurse will teach that the client should avoid eating red meat 3 days before testing, refrain from consuming citrus fruits or juices for 3 days before beginning the test, and to avoid certain raw vegetables 2-3 days prior to testing. Acetaminophen use is acceptable; nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided 7 days before self-collecting stool.

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next?

Shower, bathe, or wash peristomal area with mild soapy water. Explanation: After removal of an existing ostomy appliance, the client should be taught to clean the peristomal area or shower or bathe. Other actions take place after cleansing.

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

Stop 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 physician.

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. Explanation: Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 mL of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.

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

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. 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 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. Explanation: The nurse will teach the client to use water and mild soap to cleanse the stoma. Water only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing.

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. 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.

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

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. Peeling fruit does not impact bowel habits in the older adults.

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

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

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 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.

For which client would digital removal of stool 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.

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 Explanation: The incidence of constipation tends to be high among clients whose dietary habits lack sufficient raw fruits and vegetables, whole grains, seeds, and nuts, all of which contain adequate fiber. Dietary fiber, which becomes undigested cellulose, is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. A diet lacking in glucose and water will cause dehydration first and then constipation, depending on other constituents of the diet. Diets consisting of whole grains, seeds, and nuts provide fiber, which helps in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.

hemorrhoids:

abnormally distended rectal veins

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 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.

colostomy:

an opening into the colon that permits feces to exit through the stoma

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

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.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to:

blue. Explanation: Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.

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

bright yellow. Explanation: If newborns are fed breast milk, the stools will be bright yellow, soft, and unformed with an unobjectionable odor.

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

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.

fecal impaction:

collection in the rectum of hardened feces that cannot be passed

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 Explanation: A healthy stoma is dark pink to red and moist. Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia.

endoscopy:

direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)

defecation:

emptying of the intestinal tract; synonym for bowel movement

flatulence:

excessive formation of gases in the gastrointestinal tract

A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition?

fecal impaction Explanation: The client has fecal impaction because the large, hardened mass of stool is interfering with defecation. Iatrogenic constipation occurs as a consequence of other medical treatment. Secondary constipation is a consequence of a pathologic disorder. Fecal incontinence is the inability to control the elimination of stool.

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 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 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 Explanation: The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. 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?

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.

flatus:

intestinal gas

feces:

intestinal waste products

enema:

introduction of solution into the lower bowel

fecal incontinence:

involuntary or inappropriate passing of stool or flatus

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. Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.

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 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.

ileostomy:

opening into the small intestine allows fecal content from the ileum to be eliminated through the stoma

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

past the internal sphincter Explanation: To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

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. 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.

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

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.

A 7-month-old infant recently underwent a bowel resection for an isolated perforation. The surgeons removed most of the client's ileum. The remaining small intestine was spared, and the large intestine remains intact. Based on the nurse's knowledge of digestion, the nurse knows that the client will likely have problems with which type of nutrient absorption?

some vitamins and iron Explanation: Some vitamins and iron are absorbed in the ileum, along with a small amount of fluid. However, most of the fluid is absorbed in the large intestine. Electrolytes are predominantly absorbed in the duodenum, jejunum, and large intestine.

A nurse is caring for a 65-year-old woman who has undergone a hernia operation. The client receives morphine via patient-controlled anesthesia for postoperative pain. The client also receives sulfamethoxazole-trimethoprim every 12 hours to treat a urinary tract infection, and an iron supplement for anemia. The client is on mobility restrictions because of the narcotics. The client explains that while she usually passes stool once per day, she has passed stool four times today. The health care provider has diagnosed diarrhea. What is most likely contributing to this outcome?

sulfamethoxazole-trimethoprim Explanation: Antibiotics, such as sulfamethoxazole-trimethoprim, can cause diarrhea. Morphine, iron supplement, and immobility are likely causes of constipation.

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

vitamin B12 Explanation: The nurse anticipates that vitamin B12 will be prescribed for a client with this type of ostomy, an ileostomy. This helps prevent vitamin B12-deficiency anemia, which can occur because ileostomies are placed before the terminal ileum where vitamin B12 is absorbed.