NURS (FUNDAMENTAL): Ch 37 NCLEX Bowel Elimination

When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client? a) "Do you frequently take antacids?" b) "Do you frequently consume red meats?" c) "Do you drink lots of milk, but eat little meat?" d) "Do you take any anticoagulants?"

a) "Do you frequently take antacids?"

Which client is most likely to require interventions in order to maintain regular bowel patterns? a) A client whose neuropathic pain requires multiple doses of opioids each day. b) A client with hypertension who takes a diuretic and adrenergic blocker each morning. c) A woman 59 years of age who has recently begun hormone replacement therapy. d) A client who has a history of atrial fibrillation requiring daily anticoagulants.

a) A client whose neuropathic pain requires multiple doses of opioids each day.

A nurse is caring for a postpartum patient who has stitches in the perineum from an episotomy (surgically planned incision to prevent vaginal tears). Which medication would the nurse most likely administer to this patient? a) A stool softener (Colace) b) An osmotic laxative (Miralax) c) A bulk-forming laxative (Metamucil) d) An emollient laxative (mineral oil)

a) A stool softener (Colace) Although all the choices are laxatives that would soften the stool and make it easier to expel, a stool softener, such as Colace, is the one recommended for a patient who must avoid straining. In this case, it would help to prevent disturbing the stitches in the perineum.

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) Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.

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? a) Cleansing enema b) Return-flow enema c) Retention enema d) Carminative enema

a) Cleansing enema

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? a) Wash it with a mild cleanser and water. b) Avoid using commercial skin preparations. c) Clean it with a dry, cotton bandage. d) Avoid applying a barrier substance.

a) Wash it with a mild cleanser and water.

The nurse is conducting teaching with a client who has a prescription for a wireless capsule endoscopy. Which statement by the client would indicate to the nurse that the teaching was effective? a) "I will return 24 to 48 hours after swallowing the capsule to have the capsule removed." b) "I can go about my daily routine while the camera is passing though my small intestine." c) "I will not be allowed to eat anything after the first 4 hours of the study." d) "I will feel bloated and uncomfortable because of the air used to expand my small intestine."

b) "I can go about my daily routine while the camera is passing though my small intestine."

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: a) brown. b) bright yellow. c) dark yellow. d) beige.

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

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? a) barium studies, endoscopic examination, fecal occult blood test b) fecal occult blood test, barium studies, endoscopic examination c) barium studies, fecal occult blood test, endoscopic examination d) endoscopic examination, barium studies, fecal occult blood test

b) fecal occult blood test, barium studies, endoscopic examination

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? a) constant physical activity b) inadequate intake of liquid c) high intake of fiber d) constant urges to defecate

b) inadequate intake of liquid

Which symptom is a known side effect of antibiotics? a) Fecal impaction b) Constipation c) Diarrhea d) Abdominal bloating

c) Diarrhea

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? a) Contact the physician immediately b) Give the client the ordered laxative c) Document the output, this is normal d) Assess for obstruction

c) Document the output, this is normal

A patient has a fecal impaction. The nurse correctly administers an oil-retention enema by: a) Administering a large volume of solution (500-1,000 mL) b) Mixing milk and molasses in equal parts for an enema c) Instructing the patient to retain the enema for at least 30 minutes d) Administering the enema while the patient is sitting on the toilet

c) Instructing the patient to retain the enema for at least 30 minutes 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.

Which enema solution lubricates the stool and intestinal mucosa without distending the intestine? a) Soap b) Water c) Oil d) Normal saline

c) Oil

Which medication causes constipation? a) Aspirin b) Magnesium antacids c) Bisacodyl d) Iron supplements

d) Iron supplements 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.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? a) Cirrhosis of the Liver b) Gastroesophageal Reflux Disease (GERD) c) Chronic Constipation d) Peptic Ulcer

d) Peptic Ulcer

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? a) Ileostomy b) Transverse colostomy c) Ascending colostomy d) Sigmoid colostomy

d) Sigmoid colostomy

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? a) Slow the infusion rate, withdraw the tubing slightly, then resume enema. b) Slow the infusion rate, have the client take deep breaths, then resume enema. c) Stop the procedure and reposition the client. d) Stop the procedure, monitor heart rate and blood pressure.

d) Stop the procedure, monitor heart rate and blood pressure. 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, nausea, 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.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? a) Visible waves of abdominal peristalsis b) Increased anal area pigmentation c) Hyperactive bowel sounds d) Dry, hard stool

c) Hyperactive bowel sounds

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? a) Right side-lying b) Prone c) Left side-lying d) Supine

c) Left side-lying

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which of the following is an effect of prolonged use of mineral oil to relieve constipation? a) Causes periodic bleeding and tissue trauma b) Develops healthier bowel elimination patterns c) Reduces elasticity in intestinal walls and slows motility d) Affects absorption of fat-soluble vitamins

d) Affects absorption of fat-soluble vitamins

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? a) Digital removal of stool may cause parasympathetic stimulation. b) Most clients will not consent to have digital removal of stool. c) Nurses find the procedure distasteful and difficult to perform. d) It often causes rebound diarrhea and electrolyte loss.

a) Digital removal of stool may cause parasympathetic stimulation.

A nurse caring for patients with bowel alterations formulates a nursing diagnosis for a patient with a new ileostomy. Which diagnosis is most appropriate? a) Disturbed Body Image b) Constipation c) Delayed Growth and Development d) Excess Fluid Volume

a) Disturbed Body Image

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 clear liquid diet 24 to 48 hours before the test. b) Have the patient take Dulcolax 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) Have the patient follow a clear liquid diet 24 to 48 hours before the test. Preparation for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day 2 of the test, or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a short period of time. 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 attempts to administer a nutritive retention enema to a client who is dehydrated and finds that the client cannot retain the enema for the prescribed amount of time. What would be a recommended intervention for this client? a) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. b) Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the physician. c) Place the client in a sitting position on the toilet and lower the enema solution. d) Stop the enema and reposition the rectal tube or remove it to check for any fecal contents.

a) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. If the client cannot retain the enema solution for an adequate amount of time, place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort. If still unable to retain the solution, notify the physician.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? a) Slowly and gently insert the enema tube 3 to 4 inches (7.5 to 10 cm) for an adult. b) Position the client on his back and drape properly. c) Encourage the client to hold the solution for at least 20 minutes. d) Introduce solution quickly over a period of 3 to 5 minutes.

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

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? a) The graduate places the client in Fowler's position. b) The graduate uses a room temperature solution. c) The graduate advises the client that the enema should not be expelled immediately. d) The graduate takes this opportunity to teach about the function of the intestinal tract.

a) The graduate places the client in Fowler's position.

Which does not occur with the Valsalva maneuver? a) contraction of the external sphincter b) taking a deep breath against a closed glottis c) contracting abdominal muscles d) contracting pelvic floor muscles

a) contraction of the external sphincter

A client admitted with cellulitis of the leg has been prescribed amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy, the client develops severe diarrhea, and the nurse notifies the physician. The nurse would anticipate which course of action in response to the client's diarrhea? a) discontinuation of the amoxicillin and the administration of a different antibiotic b) discontinuation of the amoxicillin and the administration of an antidiarrheal drug c) administration of an antidiarrheal drug and continuance of the amoxicillin d) increase in the client's dietary fiber and continued administration of amoxicillin

a) discontinuation of the amoxicillin and the administration of a different antibiotic The use of antidiarrheal drugs is not recommended for diarrhea related to the administration of amoxicillin-clavulanate potassium because it will prolong the exposure of the intestinal mucosa to the irritating effects of the antibiotic and toxin. If the diarrhea is severe, the drug may need to be discontinued.

A physician orders a large-volume cleansing enema for a client. What is one of the usual outcomes of this procedure? a) removes hardened fecal impactions from the rectum b) provides an outlet for diarrhea to be funneled into a collection unit c) softens and facilitates the removal of intestinal polyps d) increases the volume of the stool, making defecation easier

a) removes hardened fecal impactions from the rectum 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.

A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation? a) tap water and soap solution b) hypertonic saline solution c) tap water and normal saline solution d) cottonseed or olive oil solution

a) tap water and soap solution

The nurse faculty is presenting a lecture on the gastrointestinal (GI) system. Which statements, if given by the nursing students, would indicate to the faculty that the lecture was effective? Select all that apply. a) "The stool becomes hard if it remains in the large intestine too long." b) "The last part of the large intestine is the rectum, not the anus." c) "Movement of the colon is stimulated by the parasympathetic nervous system." d) "The muscles of the colon are innervated by the endocrine system." e) "Vitamins D and E are produced by the bacteria action in the large intestines."

a, b, c 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 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. a) a positive family history b) a history of inflammatory bowel disease c) age 50 and older d) smoking

a, b, c 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.

The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply. a) The autonomic nervous system innervates the muscles of the colon. b) Mass peristalsis often occurs after food has been ingested. c) Peristalsis occurs every 3 to 12 minutes. d) Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people. e) The sympathetic nervous system stimulates movement

a, b, c, d The autonomic nervous system innervates the muscles of the colon. The parasympathetic nervous system stimulates movement, while the sympathetic system inhibits movement. Contractions of the circular and longitudinal muscles of the intestine (peristalsis) occur every 3 to 12 minutes, moving waste products along the length of the intestine continuously. Mass peristalsis often occurs after food has been ingested, accounting for the urge to defecate that often occurs after meals. 33% to 50% of ingested food waste is normally excreted in the stool within 24 hours.

An 86-year-old man has a history of constipation. He currently self-treats his constipation with over-the-counter laxatives. The nurse knows what to be true of these medications? Select all that apply. a) Older adults are at particular risk for laxative abuse. b) Oral laxatives take longer to effect change than laxatives administered rectally. c) All older adults should use laxatives to promote normal defecation. d) Rectal suppositories tend to work within 60 minutes of administration.

a, b, d

The nurse is selecting antidiarrheal medications for clients with diarrhea. Which statements accurately describe the action of specific antidiarrheal medications? Select all that apply. a) Loperamide is a nonaddictive antidiarrheal medication that has a longer duration of action than diphenoxylate/atropine. b) Bismuth subsalicylate contains salicylates; a physician should be consulted before giving it to children or clients taking aspirin. c) Diphenoxylate/atropine have a longer duration of action than loperamide. d) Paregoric contains morphine and may be addictive. e) Attapulgite does not interfere with the absorption of other oral medications. f) Loperamide is an antimicrobial against bacterial and viral pathogens.

a, b, d 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.

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 (Jensen, 2011)—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.

Which actions are important goals of a bowel training program for clients with spinal cord injuries? Select all that apply. a) Maintain soft stool consistency. b) Regain previous level of bowel independence. c) Prevent fecal impaction. d) Develop a routine method for stool evacuation.

a, c, d It is unlikely that a client who needs a bowel training program will regain his previous level of bowel independence. However, this does not mean that a client cannot create a new, independent norm for himself.

A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric 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 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 a nasogastric tube connected to suction should draw up 30 mL of saline solution (or 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 irrigating the colostomy of a patient and is unable to get the irrigation solution to flow. What would be the nurse's next action in this situation? a) Assist the patient to a prone position on a waterproof pad and try again. b) Check the clamp on the tubing to make sure that the tubing is open. c) Quickly pull the cone from the stoma and check for bleeding. d) Remove the equipment and call the primary care provider.

b) Check the clamp on the tubing to make sure that the tubing is open. If irrigation solution is not flowing, the nurse should first check the clamp on the tubing to make sure the tubing is open. Next, the nurse should gently manipulate the cone in the stoma and check for a blockage of stool. If there is a blockage, the nurse should remove the cone from the stoma, clean the area, and gently reinsert. Alternately, the nurse could assist the patient to a side-lying or sitting position in bed, place a waterproof pad under the irrigation sleeve, and place the drainage end of the sleeve in a bedpan.

The nurse needs to assess the client's elimination patterns. Which client will most likely deny the urge to defecate? a) Client who consumes >30 g of fiber b) Client 3 days' postvaginal birth c) Client with anxiety and depression d) Client who has a colostomy

b) Client 3 days' postvaginal birth

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? a) Provide a light meal before the test and administer two Fleet enemas. b) Ensure that the client fasts 6 to 12 hours before the test as per policy. c) Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. d) Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time.

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

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. a) True b) False

b) False

The nurse is irrigating a nasogastric tube attached to suction and finds that the flush solution is meeting a lot of force when the plunger is pushed. What would be the nurse's first intervention in this situation? a) Assess the abdomen for distention and ask the client if he is experiencing any nausea or any abdominal discomfort. b) Inject 20 to 30 mL of free air into the abdomen in attempt to reposition the tube and enable flushing of the tube. c) Attempt to flush the tube to ensure its patency. d) Check the suction canister to ensure that the suction is working appropriately.

b) Inject 20 to 30 mL of free air into the abdomen in attempt to reposition the tube and enable flushing of the tube. The nurse would inject 20 to 30 mL of free air into the abdomen in an attempt to reposition the tube and enable flushing of the tube. The situation at hand would not be related to the suction working, so there would be no need to check the suction canister to be sure that it is working appropriately. The nurse would not attempt to flush the tube to ensure its patency. The nurse would have no need to assess the client's abdomen for distention or discomfort.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: a) mucus-filled. b) liquid consistency. c) bloody. d) soft semi-formed.

b) liquid consistency.

A nurse is caring for a 65-year-old woman who has undergone a hernia operation. The client has a morphine PCA for postoperative pain. She 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. She explains that while she usually stools once per day, she has stooled four times today. What is most likely contributing to her diarrhea? a) iron supplement b) sulfamethoxazole-trimethaprim c) immobility d) morphine

b) sulfamethoxazole-trimethaprim

A 76-year-old woman immigrated to the United States from the Middle East in her 40s. She speaks limited English. Her son has brought her to the clinic because he is concerned that there is blood in her stool. The woman insists to her son that he not worry as she is treating her condition with a mixture of herbs imported from her home. Which statement applies to this client? Select all that apply. a) The client should continue to use her folk remedies and return in 6 months for follow up. b) The client may be reluctant to discuss her bowel movements in front of her son. c) Treatment for bowel changes with folk remedies is a common practice. d) The client's son can be used to interpret because of the personal nature of the concern.

b, c 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.

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. a) "The client expresses interest in learning self-care." b) "The client is willing to look at the stoma." c) "The client uses spray deodorant several times an hour to mask odor." d) "The client makes neutral or positive statements about the ostomy." e) "The client agrees to take prescribed antidepressants."

b, c, d

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. a) Wipe the lubricated tip of the container before insertion. b) Help the client into a Sims' position. c) Encourage the client to retain the solution. d) Compress the container as the solution instills. e) Cool the container holding the solution.

b, c, d When administering a hypertonic enema solution to a client, the nurse should assist the client to a Sims' position because this position promotes gravity distribution of the solution. Compressing the container as the solution instills provides positive pressure, rather than gravity, to instill fluid. Encouraging the client to retain the solution for 5 to 15 minutes promotes effectiveness. The nurse should warm, not cool, the container containing the solution for client comfort. The nurse should apply additional lubricant, not wipe the lubricated tip of the container, before insertion.

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply. a) "Where do you do your grocery shopping?" b) "How often do you move your bowels?" c) "Do you prefer hot foods or cold foods?" d) "Do you use anything to help move your bowels?" e) "How often do you go out to eat?"

b, d To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply. a) The nurse auscultates the abdomen before inspection and palpation are performed. b) The nurse places the client in the supine position with the abdomen exposed. c) The nurse encourages the client to drink fluids before the assessment so that the bladder is full and can be examined. d) The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft. e) The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. f) The nurse drapes the client's chest and pubic area and extends the client's legs flat against the bed.

b, d, e

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

b, e 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.

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 laxatives 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 (Augmentin), laxatives, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

You are caring for a 68-year-old female patient who weighs 108 pounds. The patient has been worried about regularity of her bowel movements. You have just placed a regular bedpan under the patient and the patient states, "Please leave the bedpan in place until I have a bowel movement." Which of the following responses is most appropriate? a) "Remember, you can also urinate into the bedpan." b) "Turn your call light on when you want me to come back into the room." c) "I will check back in 10 minutes and remove the bedpan for a period of time even if you have not had a bowel movement." d) "Leaving the bedpan in place for a long period of time is unusual. Are you worried that staff will not respond in a timely manner when you need to have a bowel movement?"

c) "I will check back in 10 minutes and remove the bedpan for a period of time even if you have not had a bowel movement." A bedpan should not be left in place for extended periods of time because this can result in excessive pressure and irritation to the patient's skin.

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing? a) 2 inches (5.0 cm) b) 1 inch (2.5 cm) c) 3 inches (7.5 cm) d) 5 inches (12.5 cm)

c) 3 inches (7.5 cm)

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which of the following nursing diagnoses? a) Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency b) Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis c) Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate d) Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence

c) Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

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? a) Retention enema b) Return-flow enema c) Cleansing enema d) Carminative enema

c) Cleansing enema 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 nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which of the following is a function of hypertonic saline enema? a) Lubricates and softens the stool b) Promotes bowel movement without irritation effect c) Draws fluid from body tissues into the bowel d) Causes chemical irritation of the mucous membranes

c) Draws fluid from body tissues into the bowel A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

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) Have the patient rest for 30 minutes to see if the prolapse resolves. 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 physician. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation? 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) Lower the solution container and check the temperature and flow rate. If the patient complains of 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.

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of which of the following reasons? a) Social and emotional setting of client b) Nature and amount of food eaten by client c) Physiologic or lifestyle changes in client d) Drinking and smoking habits of client

c) Physiologic or lifestyle changes in client

A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then she 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 physician. c) Stop the procedure, assess vital signs, and notify the physician. d) Stop the procedure, wait five minutes, and then resume the procedure.

c) Stop the procedure, assess vital signs, and notify the physician. When a patient complains of 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 physician. The vagal nerve may have been stimulated.

Which factor is related to developmental changes in bowel habits for older adult clients? a) Increase in dietary fiber can decrease peristalsis. b) Milk products cause constipation in clients with lactose intolerance. c) Weakened pelvic muscles lead to constipation. d) Older adults should peel fruits before eating.

c) Weakened pelvic muscles lead to constipation. Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which foods would the nurse suggest as natural intestinal deodorizers? a) Asparagus and turnip b) Onions and garlic c) Yogurt and buttermilk d) Fish and dried lentils

c) Yogurt and buttermilk Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnip, fish, onions, and garlic are foods that produce odor.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to: a) red. b) brown. c) blue. d) green.

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

A student nurse studying human anatomy knows that a structure of the large intestine is the: a) duodenum b) jejunum c) cecum d) ileum

c) cecum 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 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? a) electrolytes b) fluid c) some vitamins and iron d) all nutrients

c) some vitamins and iron

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly? Select all that apply. a) The nurse warms the oil-retention enema before administering it. b) The nurse administers a cleansing enema prior to the oil-retention enema. c) The nurse instructs the client to retain the oil for at least 30 minutes. d) The nurse administers the oil-retention enema at body temperature. e) The nurse administers a cleansing enema after the oil-retention enema. f) The nurse chooses a large rectal tube.

c, d, e The nurse would administer the oil-retention enema at body temperature. This prevents any injuries or discomfort if given at this temperature. The nurse would instruct the client to retain the enema for at least 30 minutes for best results. The nurse would administer a cleansing enema after the oil-retention enema. This would clean the colon of any oil residue after the oil-retention enema. A small rectal tube is used for the enema.

A nurse who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply. a) A client who is constipated should eat eggs and pasta to relieve the condition. b) Alcohol and coffee tend to have a constipating effect on clients. c) Clients with food intolerances may experience altered bowel elimination. d) Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. e) Clients with lactose intolerance may experience diarrhea or gas when consuming starchy foods. f) Clients who are constipated should eat more fruits and vegetables.

c, d, f

The nurse faculty is presenting a lecture on cathartics and laxatives. Which statements, if given by the nursing students, would indicate to the faculty that teaching was effective? a) "When providing teaching, I will inform the client that Metamucil usually acts within 8 hours." b) "When providing teaching, I will inform the client that mineral oil usually acts within 24 hours." c) "When giving a stimulant laxative, I will review the client's chart for prescription of vitamin D." d) "When giving an emollient, I will review the client's chart for prescription of water-soluble vitamins." e) "When giving an osmotic laxative, I will review the client's chart for a history of heart failure."

c, e A stimulant may interfere with absorption of calcium and vitamin D, so added precautions may be needed. Osmotic laxatives are not recommended in clients with heart failure or kidney disease. Emollients may interfere with absorbent of fat-soluble vitamins, so the nurse should review the client's chart for prescription of these vitamins. A bulk-forming laxative, such as Metamucil, usually acts within 24 hours. An emollient laxative, such as mineral oil, is usually effective within 8 hours.

A nurse is teaching a patient with frequent constipation how to implement a bowel-training program. What is a recommended teaching point? 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) Allowing ample time for evacuation

d) Allowing ample time for evacuation For a bowel-training program to be effective, the patient must have ample time for evacuation (usually 20-30 minutes). Fluid intake is increased to 2,500 to 3,000 mL, food high in bulk is recommended as part of the program, and a daily enema is not administered in a bowel-training program. A cathartic suppository may be used 30 minutes before the patient's usual defecation time to stimulate peristalsis.

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas build-up in the colostomy bag? a) Fresh lettuce b) Cooked pasta c) Steamed rice d) Baked beans

d) Baked beans

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? a) Risk for Impaired Skin Integrity r/t fecal incontinence b) Fecal Incontinence r/t decreased muscle tone and sphincter control c) Risk for Disturbed Body Image r/t fecal incontinence d) Diarrhea r/t decreased muscle tone and sphincter control

d) Diarrhea r/t decreased muscle tone and sphincter control

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? a) Risk for Impaired Skin Integrity r/t fecal incontinence b) Fecal Incontinence r/t decreased muscle tone and sphincter control c) Risk for Disturbed Body Image r/t fecal incontinence d) Diarrhea r/t decreased muscle tone and sphincter control

d) Diarrhea r/t decreased muscle tone and sphincter control 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? a) Allow the low intermittent suction to continue during the assessment of bowel sounds. b) Apply continuous suction to the nasogastric tube during assessment of bowel sounds. c) Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds. d) Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

d) Disconnect the nasogastric tube from suction during the assessment of bowel sounds. If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds.

The nurse is administering magnesium sulfate to a patient with constipation. What mechanism of action would the nurse expect from this drug? a) Increasing intestinal bulk to enhance mechanical stimulation of the intestine b) Chemical stimulation of peristalsis c) Softening of the fecal material d) Drawing water into the intestines to stimulate peristalsis

d) Drawing water into the intestines to stimulate peristalsis

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which of the following is a function of hypertonic saline enema? a) Lubricates and softens the stool b) Causes chemical irritation of the mucous membranes c) Promotes bowel movement without irritation effect d) Draws fluid from body tissues into the bowel

d) Draws fluid from body tissues into the bowel A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

Which statement about ostomy irrigation is true? a) Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery. b) Daily irrigation is necessary to assure passage of stool from an ileostomy. c) Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. d) For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination.

d) For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? a) The client repeatedly ignores the urge to defecate. b) The client has a daily fluid intake of 2,000 to 3,000 mL. c) The client consumes large qualities of fresh vegetables. d) The client returned from a foreign country two days ago.

d) The client returned from a foreign country two days ago.

A 5-year-old client has a gastrointestinal infection. His mother plans to send him to school tomorrow. The school nurse knows that which nursing outcome is most important to include in the care plan of the client? a) The client will not return to school until he is completely symptom free for 7 days. b) The client will inform all contacts that he is ill. c) The client will demonstrate good health practices by isolating himself from others. d) The client will demonstrate good health practices to prevent spread of infection.

d) The client will demonstrate good health practices to prevent spread of infection. Children should not, but may, return to a school or daycare setting during the infectious phase of their illness. Hand washing is key to preventing the spread of infection.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which diet? a) a diet consisting of whole grains, seeds, and nuts b) a diet lacking in glucose and water c) a diet lacking in meat and poultry products d) a diet lacking in fruits and vegetables

d) a diet lacking in fruits and vegetables

The proliferation of Clostridium difficile causes: a) anal yeast infection. b) Urinary Clostridium infection. c) Escherichia coli diarrhea. d) antibiotic-associated diarrhea.

d) antibiotic-associated diarrhea.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician 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) b, a, d, c 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 administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed? a) distends rectum and moistens stool b) irritates local tissue c) distends rectum and irritates local tissue d) lubricates and softens stool

d) lubricates and softens stool

A nurse prepares to assist a patient with her 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.