Sherpath: Bowel Elimination: implement and take action; evaluate

Which action would the nurse take for a patient with a newly formed bowel diversion?

Perform stom care him-or herself

Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient's bowel elimination needs?

Record intake and output for a frail older adult

Place the steps of ostomy care for a patient in the correct order.

Remove and dispose of the used ostomy pouch Cleanse the area surrounding the stoma Assess the integrity of the stoma and peristomal skin Measure the stoma Prepare the new pouch to fit stoma Apply the new pouch

Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant?

Senna

Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy?

Measure the stoma Assess the pouch seal Gently wash the stoma and peristomal area with water

Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health?

"Because i am 50, i need to have a fecal occult blood test every year" "Because I have no personal or family histoy of colorectal cancer and am 50 years old, sigmoidscopy or colonscopy screening should begin now"

Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent?

"I should take the medication for no more than 72 hours"

After how many enemas would the nurse notify the health care provider when the patient's bowel return for cleansing enemas is still brown? Record your answer as a whole number. enemas

3

For which patient would the nurse obtain this piece of equipment?

A patient with difficulty ambulating to the bathroom

Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient?

Assisting the patient to the bathroom Ensuring that nonskin shoes/socks are in place

Which action would the nurse take first when there is no movement of fluid in the patient's nasogastric tube and the patient's abdomen is becoming distended?

Irrigate the tube with normal saline

Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration?

Fever Congested lung sounds Shortness of breath

For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance?

Gastric lavage

Which assessment cues would alert the nurse that the patient with diarrhea is declining?

Has two more episodes of liquid stools Exihibits dry mucous membranes Exhibits poor skin turgor

Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating?

Heart rate drops 56 beats/min Blood pressure elevates from 120/60 to 142/66 mm Hg

Which action would the nurse take when the unlicensed assistive personnel (UAP) obtains this piece of equipment for a patient with a hip fracture?

Help the UAP obtain the correct piece of equipment

Based on the image below, which type of enema is the nurse administering to a patient?

Hypertonic

Which action would the nurse take if there are concerns during administration of the enema?

If the patient cannot hold the enema solution, place the patient on a bedpan

Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating?

Moist, blue

Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated?

Monitor intake and output Weigh daily Assess skin turgor

Which action would the nurse take for a patient whose ostomy stoma is speckled white?

Notify the health care provider

For which constipated patient would the nurse administer a laxative?

One who is allergic to opiates

For which patient would the nurse likely insert the nasogastric (NG) tube pictured here?

One who needs gastric decompression

Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health?

Walking stimullates intestinal muscle contractions Usually 6-8 glassess of fluid should be consumed per day