Bowel Elimination

The nurse is preparing to administer a hypertonic saline enema. How much should the nurse prepare to administer?

120 mL

A nurse inserts a rectal suppository into a middle-age female client. The client says that she has an urge to expel the suppository instantly. Which action should the nurse perform?

Ask the client to contract the gluteal muscles

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client?

Assess the color of the stoma.

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states,"I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse?

Children vary in their readiness but daytime bowel control may be attained at 30 months."

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.

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.

Which statement about ostomy irrigation is true?

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

A nurse is providing home care for a client with fecal incontinence. Which suggestions should the nurse give the client and family when managing fecal incontinence? Select all that apply.

Have the client use moisture-proof undergarments. Ask the client to monitor the pattern of incontinence. Eat nutritious foods regularly.

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply.

Help the client into a Sims' position. Compress the container as the solution instills. Encourage the client to retain the solution.

A postoperative client is reporting abdominal distention and pressure related to intestinal gas. The nurse performs a physical assessment. What percussion sound is consistent with excess flatus trapped in the intestine?

Hyperresonance

A nurse needs to administer an oil-retention enema to a client. Which intervention should the nurse perform if disposable equipment is unavailable?

Insert a 14F to 22F tube into the rectum.

During the physical examination of a client, the nurse percusses the abdomen. In which abdominal quadrant should the nurse expect to hear tympany?

Left upper quadrant

A nurse is auscultating the abdomen for bowel sounds in a client reporting abdominal pain. Which action by the nurse would be most appropriate?

Listen for 2 minutes in each quadrant.

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?

Lower solution container and check temperature and flow rate.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation?

Lower the solution container and check the temperature and flow rate.

A nurse is preparing to administer a large-volume enema to a client. The client and enema have been prepared. Place the following steps in the order in which the nurse would perform them.

Lubricate 2 to 3 in (5 to 8 cm) of the tip of the rectal tube with water-soluble lubricant. Separate the buttocks to visualize the anus. Have the client take a slow, deep breath. Gently insert the tube directing the tip toward the umbilicus. Open the clamp on the solution tubing while holding the tube in the rectum.

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

Perform a screening test on stool samples.

A nurse attempts to administer a tap water enema to a client who is dehydrated and finds that the client cannot retain the enema for the prescribed amount of time. What nursing action would be appropriate for this client?

Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.

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.

A nurse caring for an older adult client who reports flatulence suggests that the client ambulate. The nurse also administers the prescribed antiflatulent medication. Follow up reveals that the client has not obtained relief. The nurse anticipates that the physician will most likely order which type of enema?

Return-flow enema

A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply.

The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

an increase in the client's blood pressure

A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?

brown rice

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.

dark brown light brown

A 50-year-old client comes to the clinic for an annual physical examination. Which test would the nurse expect the client to undergo as a screening test for colorectal cancer?

fecal occult blood test

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

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?

large-volume cleansing enema with hypotonic solution

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply.

lentils onions cabbage

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?

lubricates and softens stool

Occult blood testing has been ordered for a hospitalized client. Which meal would be acceptable for a client receiving occult blood testing?

macaroni and cheese, corn, lettuce salad, and vanilla pudding

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

removes hardened fecal impactions from the rectum

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?

sigmoid colostomy

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather?

tap water

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?

tap water and normal saline solution

A client is prescribed a large volume cleansing enema and is concerned as to why the large volume is indicated. What response should the nurse give to the client? Select all that apply.

to relieve constipation to prevent involuntary escape of fecal material during surgical procedures to promote optimal visualization of the colon during a colonoscopy

A client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply.

whether the client is taking new medication the client's normal bowel habits if the client feels a sensation of rectal fullness if the client has used laxatives in the past

The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount

A client informs a nurse that he has had difficulty defecating over the past 6 months. He describes his stools as firm and pebble-like and sometimes he must strain to relieve himself. In order to diagnose this client with constipation using the Rome III criteria, what percentage of stool must be affected?

25%

Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order.

Cleanse entire perianal area and pat dry. Apply skin protectant and allow it to dry. Separate buttocks and apply the pouch to the anal area. Attach the pouch to a urinary drainage bag. Hang the drainage bag below the client.

The nurse has assessed the client, analyzed the data, and identified constipation as a client problem. Which assessment data would support constipation? Select all that apply.

Client reports frequency of daily bowel movements as every 3 to 4 days. Client states straining when having a bowel movement. Stool is hard and has a consistency of small "marbles."

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.

Clients who are constipated should eat more fruits and vegetables. Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. Clients with food intolerances may experience altered bowel elimination.

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

A nurse follows a physician's order to administer an oil-retention enema to a constipated adult client. Which action is a recommended guideline for this procedure?

Direct the rectal tube at an angle pointing toward the umbilicus.

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.

A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take?

Facilitate a more private setting, such as assisting the client to a bathroom.

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.

False

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable.

False

Which actions are important goals of a bowel training program for clients with spinal cord injuries? Select all that apply.

Maintain soft stool consistency. Develop a routine method for stool evacuation. Prevent fecal impaction

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply.

The client has a history of chronic renal failure. The client has an elevated phosphorus level. The client has a history of left sided heart failure.

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly? Select all that apply.

The nurse administers the oil-retention enema at body temperature. The nurse instructs the client to retain the oil for at least 30 minutes. The nurse administers a cleansing enema after the oil-retention enema.

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.

The nurse places the client in the supine position with the abdomen exposed. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.

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.

Treatment for bowel changes with folk remedies is a common practice. The client may be reluctant to discuss bowel movements in front of a health care provider of the opposite sex.

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?

briefly clamping the tubing while the client breathes deeply

The nurse is obtaining a health history from a client. The client states, "I have to take laxatives every day or I don't have a bowel movement." What primary risk does the nurse need to assess for among clients who use laxatives long term?

dependence

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 health care provider. The nurse would anticipate which course of action in response to the client's diarrhea?

discontinuation of the amoxicillin and the administration of a different antibiotic

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag?

formed

A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing?

hemorrhoids

A nurse is caring for a client with ascites due to liver failure. Which action would be a priority assessment?

measurement of abdominal girth

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?

mineral oil

Which factors can affect bowel elimination? Select all that apply.

mobility diet fluid intake medications sensory impairments

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

A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis?

stool sample

A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma?

water and mild soap

A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.

weak abdominal muscles severe dehydration unrelieved constipation