Chapter 38: Bowel Elimination

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.

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care."

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk?

Encourage physical activity to improve bowel regularity.

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?

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.

False

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

Which medication causes constipation?

Iron supplements, opioidsf

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.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

The NG tube is in the client's airway.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

The most common indications for fecal occult blood tests are anemia, concern for gastrointestinal bleeding, peptic ulcer, and colon cancer screening.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the health care provider?

The stoma is prolapsed.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

The student instructed the client to urinate before beginning the focused assessment.

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?

Wash it with a mild cleanser and water.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

yellow clay colored black

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?

3 in (7.5 cm)

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes.

What type of enema is a hypertonic enema?

Also known as a "Fleet Enema." The hypertonic solution draws water into the intestines, which promotes defecation. However, this should not be given to patients that are dehydrated, due to the intestines pulling water out of the system.

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure?

Assist the client to a 30- to 45-degree position, unless this is contraindicated.

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

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 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?

cleansing enema

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

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

discontinuation of the amoxicillin and the administration of a different antibiotic

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?

fecal occult blood test, barium studies, endoscopic examination

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

in the stomach and intestines, parasympathetic stimulation of M receptors leads to increased motility and relaxation of sphincters Digital removal of stool may cause parasympathetic stimulation.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds