Fundamentals - Chapter 30: Bowel Elimination Care
The nurse is monitoring stools from different patients. Which findings would the nurse expect to observe? (SATA) 1. A patient with gallbladder disease has clay-colored stools. 2. A patient with steatorrhea has stools that float and are fluffy with a foul odor. 3. A patient with bleeding from the small intestine has bright red blood in the stools. 4. A patient with colon cancer has ribbon-shaped stools. 5. A patient with bleeding from the colon has melena.
1. A patient with gallbladder disease has clay-colored stools. 2. A patient with steatorrhea has stools that float and are fluffy with a foul odor. 4. A patient with colon cancer has ribbon-shaped stools.
Several medications have GI side effects and may lead to diarrhea or constipation. Indicate which of the following medications would be most likely to cause constipation in the patient? (SATA) 1. Amphojel 2. Maalox 3. Magnesium citrate 4. Meperidine 5. Amoxicillin 6. Ferrous sulfate (iron) 7. Imodium AD 8. Milk of magnesia
1. Amphojel 4. Meperidine 5. Amoxicillin 7. Imodium AD
A patient is obtaining a stool specimen for occult blood from home. The nurse is reinforcing dietary restrictions for this test. Which items should the nurse tell the patient to avoid? (SATA) 1. Cherry limeade 2. Broiled steak 3. Vitamin D supplements 4. Steamed broccoli 5. Cooked carrots
1. Cherry limeade 2. Broiled steak 4. Steamed broccoli
The nurse is preparing to administer an enema. Which patient findings would cause the nurse to notify the health-care provider or charge nurse? (SATA) 1. Has a history of unstable angina 2. Is admitted with Crohn's disease 3. Observes a rectal fissure 4. Has infrequent hard stools 5. Observes severely bleeding hemorrhoids
1. Has a history of unstable angina 2. Is admitted with Crohn's disease 3. Observes a rectal fissure 5. Observes severely bleeding hemorrhoids
The nurse is administering an enema to a patient who is constipated. Which action should the nurse take? 1. Insert the tubing 3 to 4 inches (7.6 to 10.2 cm) into the rectum. 2. Warm water to 120° F (48.9° C). 3. Administer enema with patient on the toilet. 4. Check to make sure water feels cool on inner wrist.
1. Insert the tubing 3 to 4 inches (7.6 to 10.2 cm) into the rectum.
The nurse is collecting data from several patients. Which findings would cause the nurse to monitor closely for constipation? (SATA) 1. Is immobile due to skeletal traction 2. Eats three daily meals a day at 7 a.m., noon, and 5 p.m. 3. Is postoperative from a hip surgery 4. Takes hydrocodone to help with back pain 5. Is dehydrated from working out in the sun
1. Is immobile due to skeletal traction 3. Is postoperative from a hip surgery 4. Takes hydrocodone to help with back pain 5. Is dehydrated from working out in the sun
Which of the following factors is most likely to result in diarrhea? 1. Loss of intestinal normal flora 2. Drinking excessive fluids 3. Administration of opioid narcotics 4. Manipulation of intestines during colon surgery 5. Eating 10-15g of fiber per day
1. Loss of intestinal normal flora
The nurse would monitor which patients for diarrhea? (SATA) 1. One who eats ice cream and has lactose intolerance 2. One who has Clostridium difficile 3. One who has inflamed diverticula 4. One who is stressed about an upcoming surgery 5. One who is allergic to strawberries and does not eat strawberries
1. One who eats ice cream and has lactose intolerance 2. One who has Clostridium difficile 3. One who has inflamed diverticula 4. One who is stressed about an upcoming surgery
A patient has a vagal response to administration of an enema. Which action by the nurse is priority? 1. Remove the tube from the rectum. 2. Place in high Fowler's position. 3. Leave the patient to go get help. 4. Slow the rate of the enema.
1. Remove the tube from the rectum.
The nurse wants to determine if peristalsis is occurring in a patient. Which piece of equipment should the nurse obtain? 1. Stethoscope 2. Thermometer 3. Blood pressure cuff 4. Enema bag
1. Stethoscope
The patient is to receive a cleansing enema for relief of constipation. Which of the following factors must be assessed prior to administration of the enema? (SATA) 1. Type of solution to administer 2. Date of last bowel movement 3. Type of diet the patient has been receiving 4. Assessment of the bowel sounds 5. The patient's temperature
1. Type of solution to administer 2. Date of last bowel movement 4. Assessment of the bowel sounds
A patient is on a bowel training program. At which times would the nurse assist the patient to defecate? (SATA) 1. Upon awakening 2. Any time the patient states that he or she has to move bowels 3. After breakfast, lunch, and supper 4. After drinks a pitcher of water 5. Upon bedtime
1. Upon awakening 2. Any time the patient states that he or she has to move bowels 3. After breakfast, lunch, and supper
The nurse needs to determine if a patient is experiencing tenesmus. Which question should the nurse ask? 1. "Do you have pain with defecation?" 2. "Do you have urgency or pressure in the rectum?" 3. "Do you have any abnormal color in your stools?" 4. "Do you have formed or unformed stools?"
2. "Do you have urgency or pressure in the rectum?"
A patient presents to the clinic with unexplained diarrhea. Which question should the nurse ask to help determine the cause of the diarrhea? 1. "How much fluid do you drink?" 2. "Have you taken an antibiotic recently?" 3. "How often do your bowels normally move?" 4. "Does your mother have diverticulosis?"
2. "Have you taken an antibiotic recently?"
The nurse is assigning the administration of an enema to the unlicensed assistive personnel (UAP). Which statement by the UAP indicates the UAP is safe to administer the enema? 1. "I will gently insert the tube upon resistance." 2. "I will insert the tubing toward the umbilicus." 3. "I will insert the tube at least 6 inches (15.2 cm) into the rectum." 4. "I will gently insert the tubing with the patient in the right side-lying position."
2. "I will insert the tubing toward the umbilicus."
A patient is incontinent of stool. How should the nurse respond? 1. "Not again." 2. "Let's get those briefs changed." 3. "What is wrong with you?" 4. "I will put this diaper on you quickly."
2. "Let's get those briefs changed."
A patient asks the nurse why Lactobacillus acidophilus is being given when antibiotics are being given for a bowel infection. How should the nurse respond? 1. "This makes the antibiotics stronger." 2. "This replaces the normal bacteria that is lost from the antibiotic." 3. "This coats the inside of the infectious bowel." 4. "This helps slow down the wavelike movement in the inflamed bowels."
2. "This replaces the normal bacteria that is lost from the antibiotic."
A patient has a fecal impaction that requires digital removal and an oil retention enema. Which actions should the nurse take? (SATA) 1. Assign fecal impaction removal to the unlicensed assistive personnel (UAP). 2. Administer pain medication before the digital removal. 3. Monitor for vagal nerve stimulation. 4. Administer the oil retention enema after digital removal. 5. Check for heart problems before the digital removal.
2. Administer pain medication before the digital removal. 3. Monitor for vagal nerve stimulation. 5. Check for heart problems before the digital removal.
Which of the following would be the most accurate statement about digestion and elimination? 1. All individuals have at least 1 bowel movement daily 2. An infant may have up to 6 bowel movements daily 3. GI peristalsis increases with age, making incontinence a normal finding 4. A stool is only considering normal if the color is a shade of brown
2. An infant may have up to 6 bowel movements daily
The nurse is administering an enema to a patient. Which action should the nurse take? 1. Lubricate tube with petroleum-based lubricant. 2. Gradually raise the container 12 to 18 inches (30.5 to 45.7 cm) above the patient's hip level. 3. If resistance is felt, open the tubing to allow a large amount of fluid to flow. 4. Elevate the container if the patient reports cramping.
2. Gradually raise the container 12 to 18 inches (30.5 to 45.7 cm) above the patient's hip level.
The nurse assisted with a staff education program about bowel elimination. Which statement by a staff member indicates successful teaching? 1. "The process of bowel elimination is feces." 2. "Most of the digestion occurs in the stomach." 3. "The sphincter between the stomach and the small intestine is the pyloric sphincter." 4. "The normal flora interacts with the chyme to produce peristalsis or wavelike movements."
3. "The sphincter between the stomach and the small intestine is the pyloric sphincter."
The nurse is administering different types of enemas to different patients. Based upon each patient's condition, which enemas would the nurse administer? (SATA) 1. Administer tap water enemas to a patient with congestive heart failure. 2. Heat milk and molasses together and then cool before administering to a patient with constipation. 3. Give a Harris flush to a patient with flatus. 4. Administer a steroid enema to a patient with inflammation in the rectum and colon. 5. Give hypertonic sodium phosphate enema 1 hour before removing the patient's impaction
2. Heat milk and molasses together and then cool before administering to a patient with constipation. 3. Give a Harris flush to a patient with flatus. 4. Administer a steroid enema to a patient with inflammation in the rectum and colon.
A patient has a Kock pouch. Which technique would the nurse use? 1. Replace the bag when one-third to one-half full. 2. Insert a catheter to drain the pouch. 3. Store the external pouch below the stoma. 4. Make sure the patient wears the bag constantly.
2. Insert a catheter to drain the pouch.
The nurse suspects a patient has occult bleeding and performs a guaiac test. Which actions should the nurse take? (SATA) 1. Put toilet paper in the specimen pan. 2. Obtain specimen from two different areas of the stool. 3. Watch for a bluish color, which is a positive result. 4. Place developer on opposite side of the card from the specimens. 5. Use sterile gloves.
2. Obtain specimen from two different areas of the stool. 3. Watch for a bluish color, which is a positive result. 4. Place developer on opposite side of the card from the specimens.
What of the following would be the best enema to administer to a patient before digital removal of an impaction? 1. Siphon enema 2. Oil retention enema 3. Soapsuds enema 4. Harris flush enema
2. Oil retention enema
Which older adult patient should the nurse monitor closely for a fecal impaction? 1. One who eats fruits and vegetables every day 2. One who overuses laxatives 3. One who drinks 2500 mL of fluid a day 4. One who exercises at least three times a week
2. One who overuses laxatives
Which type of nurses are caring for patients that are most prone to dehydration from diarrhea? 1. Long-term care facility 2. Pediatric unit 3. Adolescent unit 4. Assisted-living facility
2. Pediatric unit
Which of the following signs and symptoms may be an indication of vagal stimulation during the digital removal of an impaction? (SATA) 1. Complaint of rectal pressure 2. Pulse rate of 42 bpm 3. Complaint of difficulty breathing 4. Moist skin 5. Complaint of abdominal cramping 6. Complaint of feeling faint
2. Pulse rate of 42 bpm 3. Complaint of difficulty breathing 6. Complaint of feeling faint
Which information would the nurse share with a patient who wants to increase fiber in the diet? 1. Eat 35 to 40 g/day of fiber. 2. Slowly increase fiber intake over 7 to 10 days. 3. Increase caffeine intake with the fiber. 4. Decrease intake of fluid when eating fiber.
2. Slowly increase fiber intake over 7 to 10 days.
A patient reports having diarrhea for 12 hours. Which fluids would the nurse encourage the patient to drink? (SATA) 1. Apple juice 2. Sports drink containing electrolytes 3. Iced green tea 4. Chamomile tea 5. Frozen lemonade
2. Sports drink containing electrolytes 4. Chamomile tea
The well-baby clinic nurse is reinforcing teaching to a new breastfeeding mother about her infant's stool. The nurse should share which information about the infant's stools? 1. The stools will be meconium. 2. The stools will be bright yellow and seedy. 3. The stools will be tan-colored and firm. 4. The stools will be very dark brown and sticky.
2. The stools will be bright yellow and seedy.
The nurse is preparing to administer a cleansing enema to a small child. How many milliliters (mL) of fluid would the nurse administer? 1. 1000 2. 500 3. 150 4. 50
3. 150
The unlicensed assistive personnel (UAP) is providing care to an elderly, confused patient with constipation. Which action by the UAP would the nurse praise? 1. Offers the patient fluid every hour 2. Provides privacy by leaving the patient alone on the bedside commode 3. Assists the patient with meals while sitting in the chair 4. Keeps head of bed flat when using the bedpan
3. Assists the patient with meals while sitting in the chair
A patient is taking iron for low red blood cells. The nurse would expect the patient's feces to be which color? 1. Green 2. Red 3. Black 4. Tan
3. Black
A patient is wearing a fecal incontinence pouch. Which action should the nurse take? 1. Drain the bag when it is three-fourths full. 2. Apply the water-soluble barrier ring to the patient's anus. 3. Change the bag every 2 to 3 days. 4. Document the contents as intake.
3. Change the bag every 2 to 3 days.
The nurse is contributing to the community health program to parents of young children about bowel elimination. Which information should the nurse include? 1. Children develop bowel control around 5 years of age. 2. Infants have about six to eight bowel movements a day. 3. Children usually have about one to two stools a day. 4. Infants are prone to constipation.
3. Children usually have about one to two stools a day.
The nurse is collecting data about a patient's new stoma. Which finding would require the nurse to notify the health-care provider? 1. Edematous stoma 2. Red, shiny stoma 3. Dusky stoma 4. Moist stoma
3. Dusky stoma
A female patient is recovering from abdominal surgery 2 days ago. Her abdomen is distended and firm, and she complains of moderate to severe cramping and abdominal discomfort. As of yet, she has been unable to pass much flatus rectally. Which type of enema would be most helpful for this patient? 1. Fleet Phospho-Soda enema 2. Oil retention enema 3. Harris flush enema 4. Small-volume enema
3. Harris flush enema
The nurse is caring for several patients who have colostomies. Which patient does the nurse expect to have the most liquid effluent? 1. One who has a transverse colostomy 2. One who has a sigmoid colostomy 3. One who has an ascending colostomy 4. One who has a descending colostomy
3. One who has an ascending colostomy
A patient is having hard, infrequent stools. Which action should the nurse take? 1. Restrict fluid 2. Place on bedrest 3. Suggest eating yogurt 4. Decrease fiber intake
3. Suggest eating yogurt
The nurse is caring for a patient who has a colostomy. Which action should the nurse take? 1. Determine the correct size by letting 3/8 inch of peristomal skin show. 2. Rinse the bag in hot water before reapplying. 3. Wash the stoma and skin with warm water and soap. 4. Change the wafer faceplate every 7 days.
3. Wash the stoma and skin with warm water and soap.
The nurse is preparing to administer a high enema. Place the steps in order the nurse should follow. 1. Finish administering the enema 2. Then turn patient to back 3. Then turn patient to the right side 4. Place patient in left Sim's position 5. Administer about half of the enema
4,5,2,3,1
The unlicensed assistive personnel (UAP) reports to the nurse that a patient is having diarrhea. The nurse collects data from the patient and observes liquid stool seepage. How should the nurse interpret this finding? 1. "I should tell the UAP the difference between diarrhea and incontinence." 2. "I should praise the UAP and administer antidiarrheal medication to the patient." 3. "I should praise the UAP and notify the health-care provider of the diarrhea." 4. "I should tell the UAP the difference between diarrhea and a fecal impaction."
4. "I should tell the UAP the difference between diarrhea and a fecal impaction."
The nurse reinforces teaching with a patient who has an ileostomy. Which statement by the patient indicates a correct understanding of the teaching? 1. "I will be able to remove the pouch after several months." 2. "I will just lose stool through the ostomy." 3. "I will have semisoft, mushy fluid from the ostomy." 4. "I will clean the stool from my skin because it can be harmful."
4. "I will clean the stool from my skin because it can be harmful."
The nurse is collecting data about a patient's bowel functioning. Which action should the nurse take? 1. Palpate the abdomen and then auscultate. 2. Listen to at least one of the four abdominal quadrants. 3. Inspect the abdomen last for distention. 4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard.
4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard.
The nurse is assisting a patient in irrigating a colostomy in order to train the bowel to have a bowel movement every day after breakfast. Which type of ostomy is the nurse helping the patient to train? 1. Left transverse colostomy 2. Right transverse colostomy 3. Ascending colostomy 4. Descending colostomy
4. Descending colostomy
The nurse is checking the intake and output record for several patients. Which finding would alert the nurse to a potential problem? 1. Intake 2500 mL and output 2300 mL 2. Intake 1500 mL and output 1800 mL 3. Had three bowel movements on Tuesday and two bowel movements on Wednesday 4. Had last bowel movement on Monday and it is now Thursday
4. Had last bowel movement on Monday and it is now Thursday
The nurse suspects a patient had a vagal response to the cleansing enema. Which finding would support the nurse's conclusion? 1. Skin flushed 2. Temperature 103° F (39.4° C) 3. Blood pressure 160/110 4. Heart rate 35 beats per minute
4. Heart rate 35 beats per minute
The nurse is collecting data from several patients who have diarrhea. Which patient would the nurse monitor most closely for dehydration? 1. Teenager 2. Young adult 3. Middle-aged adult 4. Older adult patient
4. Older adult patient
The nurse is checking for blood in the stool. Which specimen should the nurse obtain? 1. One for a sensitivity test 2. One for an ova and parasite test 3. One for a culture test 4. One for a guaiac test
4. One for a guaiac test
Which of the following assessment data might indicate the patient is having difficulty accepting his or her new colostomy? 1. Asks questions about how to take care of the colostomy 2. Observe as you irrigate the colostomy 3. Looks at stoma and makes good eye contact with you during ostomy care 4. Refuses to attempt care, and tells you to "just do it"
4. Refuses to attempt care, and tells you to "just do it"
A patient is having diarrhea. Which technique should the nurse use to clean the perineal area? 1. Use soap and water. 2. Use a cool washcloth. 3. Use alcohol wipes. 4. Use a patting motion to dry.
4. Use a patting motion to dry.
