Chapter 38: Bowel Elimination

The nurse is caring for four clients with diarrhea. When reviewing the client's chart, the nurse would contact the health care provider if which client has a prescription for an antidiarrheal agent? Client with alcohol use Client with Crohn's disease Client with food poisoning Client with a bowel tumor

Client with food poisoning Clients with acute diarrhea (food poisoning) should not receive an antidiarrheal until a bacterial causative agent is ruled out. Clients with chronic diarrhea (Crohn's disease, bowel tumor, and alcohol use) may require pharmacologic intervention.

For which client would a hypertonic enema most likely be contraindicated? A client who has peripheral edema A client who is severely constipated A client with renal impairment A client with type 1 diabetes

A client with renal impairment Hypertonic solutions are contraindicated for clients with renal impairment or reduced renal clearance, because these clients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia. Diabetes, constipation, and edema do not necessarily contraindicate the safe and effective use of a hypertonic enema.

The nurse prepares to collect the client's stool for ova and parasites. Which actions should the nurse provide? Select all that apply. Instruct client to call immediately after having the bowel movement. Use a biohazard bag for the specimen. Place stool in sterile container and label according to policy and procedure. Transport specimen to the lab immediately. Teach client to not place toilet paper with stool.

Instruct client to call immediately after having the bowel movement. Use a biohazard bag for the specimen. Transport specimen to the lab immediately. Teach client to not place toilet paper with stool.

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?

Left side-lying 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 nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer? Anthelmintic Oil-retention Carminative Hypertonic

Oil-retention

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Stop the administration of the enema momentarily. Stop the administration of the enema and notify the physician. Increase the flow of the enema until all of the solution has been administered. Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate.

Stop the administration of the enema momentarily. If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? blood pressure 130/80 mm Hg heart rate 90 beats/min temperature 99.9°F (37.9°C) skin turgor response 5 seconds

skin turgor response 5 seconds Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. Other assessment findings are normal.

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 mineral oil alcohol-based sanitizer saline

water and mild soap

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration? semi-Fowlers prone supine Sims

Sims

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? "This test detects heme, a type of iron compound in blood in the stool." "This test will show if you have an infection in the bowel." "This test will show if you have colorectal cancer." "This test will determine whether foods are contributing to rectal bleeding."

"This test detects heme, a type of iron compound in blood in the stool." The nurse will teach the client that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

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? "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." "You are putting too much pressure on yourself and your child to toilet train." "There may be something wrong since your child should be toilet trained by 2 years-old." "Children vary in their readiness but daytime bowel control may be attained at 30 months."

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

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct? "This enema will assist in your bowel regimen when you go home." "I will administer enemas until the enema return is without stool." "I will administer up to three enemas as prescribed." "You will need to have enemas unless you can consume clear liquids without nausea."

"I will administer enemas until the enema return is without stool." "Enemas until clear" means that the nurse would administer enemas until no more stool is noted on output. A nurse would not be able to determine if the entire intestinal tract is clear. Administering three enemas is not what the prescriber ordered. Consuming clear liquids does not impact the use of enemas. The enema may not be part of the client's discharge instructions.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response? "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." "It is important that you discontinue this type of treatment immediately." "This is good to help bowels move." "Perhaps you should do this twice daily."

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? "This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." "This will determine what foods you are allergic to that affect digestion and elimination." "This test will help determine whether you have an infectious process in the intestines." "This test detects heme, an iron compound in blood within the stool."

"This test detects heme, an iron compound in blood within the stool."

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? Hyperactive bowel sounds Increased anal area pigmentation Visible waves of abdominal peristalsis Dry, hard stool

Hyperactive bowel sounds Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.

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. Instill digestive enzymes, as ordered. Remove the NG tube and replace it with a larger-bore tube, as ordered. Turn off the suction for 30 minutes and then turn it on again.

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

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? Drink orange and grapefruit juice Consume citrus fruits Take 500 mg Avoid more than 250 mg

Avoid more than 250 mg The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? Administer an oral analgesia 30 to 45 minutes before attempting insertion. Position the bed flat and assist the client onto his or her left side. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point.

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. To insert a nasointestinal tube, the nurse should measure the tube from the tip of nose to the earlobe and from the earlobe to the xiphoid process and add 8 to 10 in (20 to 25 cm) for intestinal placement. The client should be placed on his or her right side. Analgesia is not normally required in anticipation of placement.

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

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

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

Diarrhea

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

Digital removal of stool may cause parasympathetic stimulation. The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

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 the suction for 1 hour prior to the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. Replace the NG tube if the client experiences nausea within 6 hours of removal. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied.

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.

The nurse is changing a client's ostomy appliance and observes that the peristomal skin is excoriated. What would be the nurse's priority intervention in this situation? Notify the primary care provider. Clean outside of bag thoroughly when emptying. Suspect ischemia and notify the primary care provider immediately. Make sure that the appliance is not cut too large.

Make sure that the appliance is not cut too large. The nurse would make sure that the appliance is not cut too large. Skin that is exposed inside of the ostomy appliance will become excoriated from the acidity of the stool. The nurse would not need to clean the outside of the bag because the peristomal skin is around the stoma and not exposed to the outside of the bag. The nurse would not suspect ischemia if the stoma was the normal color of pinkish-red. Excoriated peristomal skin does not indicate ischemia. The nurse could possibly notify the primary care provider of the situation, but this is not the best answer.

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? Sims supine prone semi-Fowler's

Sims

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

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

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

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, 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.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? The stoma is prolapsed. The stoma has a small amount of bleeding. The stoma is pink. The stoma is on the abdominal surface.

The stoma is prolapsed.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? Use alcohol-based sanitizer. Use mineral oil. Use water only. Use water and mild soap.

Use water and mild soap.

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

Weakened pelvic muscles lead to constipation.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods? Soda crackers and chicken noodle soup Cream of wheat and applesauce Whole wheat spaghetti and broccoli Hot tea and flavored water

Whole wheat spaghetti and broccoli

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

Yogurt and buttermilk

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 history of inflammatory bowel disease a diet high in fruits, vegetables, and whole grains. age 50 and older a positive family history

a history of inflammatory bowel disease age 50 and older a positive family history

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

cecum

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? retention enema carminative enema return-flow enema cleansing enema

cleansing enema

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

fecal occult blood test, barium studies, endoscopic examination There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

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 Large-volume cleansing enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. Oil-retention enemas: lubricate the stool and intestinal mucosa, making defecation easier.

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

liquid consistency Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: nature and amount of food eaten by the client. physiologic or lifestyle changes in the client. social and emotional setting of the client. drinking and smoking habits of the client.

physiologic or lifestyle changes in the client. Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence.