Bowel elimination
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A. Place the client in the dorsal recumbent position on a bedpan. B. Administer the enema while the client sits on the toilet. C. Administer an anti-diarrheal medication 3 hours prior to the enema. D. Instill 200mL of fluid over an hour at 15 minute intervals.
A
Colostomy
Surgically created when a portion of the colon or the rectum is removed and the remaining colon is brought through the abdominal wall.
Diarrhea
Intestinal disorder that is characterized by an abnormal frequency and fluidity of bowel movements.
Impaction
Refers to the presence of a hard fecal mass in the rectum or colon that the patient is incapable of expelling.
A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? A. Warm the solution prior to instillation. B. Prepare 1,500mL of enema solution. C. Use tap water as the enema fluid. D. Hang the enema container 24in above the anus.
A
A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? A. Prone B. Dorsal recumbent C. Right lateral with both knees at chest D. Left lateral with the right leg flexed
D
Stoma
Refers to the actual exit point for a GI surgical ostomy, which forms a slight protuberance of mucosa through the skin.
Peristalsis
The mechanism of progressive contraction and relaxation of the walls of the intestine.
Flatulence
The production of a mixture of gases in the intestine, by-products of the digestive process.
Ileostomy
A surgically created opening in the small intestine, usually at the end of the ileum.
A client who is post operative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enema? A. Cleansing B. Return flow C. Medicated D. Oil retention
B
A nurse is administering a return-flow enema to a client. After instilling 100mL of enema fluid, which of the following actions should the nurse take? A. Instruct the client to retain the fluid. B. Lower the container to allow the solution to flow back out. C. Help the client to the toilet or bedside commode. D. Wait 5 minutes and instill another 100mL of fluid.
B
Constipation
Having infrequent or difficult bowel movements, as well as having fewer than 3 bowel movements per week.
Ostomy
A surgically created opening in a GI, urinary, or respiratory organ that is exited onto the skin.
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube. A. 2.5cm to 3.75cm (1-1.5in) B. 5cm to 7.5cm (2-3in) C. 7.5cm to 10cm (3-4in) D. 10cm to 12.5cm (4-5in)
C
While the nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Measure the client's vital signs. B. Notify the primary care provider. C. Lower the enema fluid container. D. Stop the enema instillation.
C
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations. A. The duration of the procedure. B. 10 to 15 minutes. C. Until the client feels the urge to defecate. D. At least 30 minutes.
D
Cathartics
Strong laxatives that stimulate evacuation of the bowel by causing a change in GI transit time.
