Chapter 40: Bowel Elimination

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse? a. Assist the patient to ambulate in the hall. b. Insert a rectal tube to remove retained flatus. c. Administer an enema to stimulate peristalsis. d. Encourage oral intake of fluids and high-fiber foods.

ANS: A Ambulation is a good way to promote peristalsis and relieve bloating. An enema should not be used after colonoscopy. A rectal tube is not needed. Eating high-fiber foods soon after colonoscopy may increase gas and bloating. DIF: Understanding REF: p. 1055 | p. 1058

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient's new symptoms? a. C. difficile infection b. Paralytic ileus c. Fecal impaction d. Salmonella food poisoning

ANS: A Diarrhea, abdominal pain, and low-grade temperature after completing IV antibiotics are often caused by C. difficile infection. DIF: Understanding REF: pp. 1046-1047

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient is recovering from a traumatic brain injury. b. The patient has not had a bowel movement for 3 days. c. The patient is to have a lower GI series the following morning. d. The patient had an upper GI series performed the previous day.

ANS: A Patients with a traumatic brain injury often have increased intracranial pressure, which can be worsened with enema administration, thus putting the patient at risk for additional neurologic damage. The physician should be contacted and the order should be questioned. Constipation, preparation for a lower GI series, and removal of barium from the colon after upper GI series are all indications for a cleansing enema. DIF: Applying REF: p. 1063

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient? a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. Privacy will be provided once the patient is properly positioned on the toilet.

ANS: A The highest priority goal for this patient is continence with no perineal skin breakdown to maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to pull up clothing are less important. Privacy is an intervention to be performed by the staff rather than a goal for the patient. DIF: Applying REF: p. 1058

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function? a. Raisin bran with skim milk, fresh fruit, and wheat toast b. Pancakes with maple syrup, bacon, and coffee with cream c. Omelet with cheddar cheese, green pepper, and onions d. Bagel with cream cheese, and strawberry non-fat yogurt

ANS: A The postoperative patient taking narcotic pain medications is at risk for developing constipation. A high-fiber diet with plenty of liquids will help prevent this from occurring. Raisin bran, fruit, and wheat bread are all good sources of fiber. DIF: Applying REF: p. 1051

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon? a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient's nasogastric tube was discontinued the previous day.

ANS: A The presence of bowel sounds and passage of flatus indicate that the patient's bowels are starting to resume function and the patient will be able to resume oral intake soon. Hunger, discontinuation of the NG tube, or absence of nausea are not definite indicators of readiness to resume oral feedings. DIF: Applying REF: p. 1052

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient's dinner tray since they are not allowed prior to the test? (Select all that apply.) a. Cherry-flavored gelatin b. Cream of chicken soup c. Glass of apple juice d. Coffee with cream and sugar e. Lemon-flavored Italian ice f. Can of ginger ale

ANS: A, B, D Patients who will undergo colonoscopy testing should have a clear liquid diet the day before the exam, so cream of chicken soup and coffee creamer should not be consumed. Foods with red food coloring should also be avoided prior to colonoscopy. DIF: Applying REF: p. 1055

The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient has skin breakdown from loose stools b. The patient is constipated with last BM 3 days ago c. The patient is on a low-fiber, gluten-free diet d. The patient has painful bleeding hemorrhoids

ANS: B Lomotil is an anti-diarrheal medication. It should not be given to patients who are constipated because it will make it even more difficult for the patient to pass soft, formed stools. The other assessment findings are not contraindications to Lomotil. DIF: Understanding REF: p. 1047 | p. 1059

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam? a. "The back of your throat will be sprayed with numbing medicine." b. "You will need to have a clear liquid diet and take a laxative tonight." c. "You will be given a milky liquid to drink shortly before the test starts." d. "You should not take your dose of warfarin (Coumadin) tonight."

ANS: C The patient is given a milky barium liquid to drink as part of the upper GI series, so the patient should be informed of this. The back of the throat is numbed for upper GI endoscopy, not an upper GI series. Coumadin is not contraindicated prior to an upper GI series, and no bowel prep is required. DIF: Understanding REF: p. 1054

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor? a. Water-soluble lubricant is applied to the end of the enema tubing. b. The enema tubing is primed with solution that has been warmed. c. The patient is positioned comfortably in the right side-lying Sims position. d. The patient's bedpan is put at the bedside in preparation for use.

ANS: C The patient should be placed in the left side-lying Sims position prior to enema administration so that the enema fluid will readily flow through the colon without having to go uphill. The other actions demonstrate correct enema administration steps. DIF: Remembering REF: p. 1064

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing? a. Keep the patient on a clear liquid diet for 72 hours. b. Send the samples to the laboratory while they are still warm. c. Inform the patient that several stool samples will be needed. d. Use a sterile container when collecting the stool samples.

ANS: C Three stool samples are required for fecal occult testing in order to avoid missing blood that appears intermittently. A sterile container is not required, and the patient does not need to be on a clear liquid diet for the test. Stool samples for culture and sensitivity should be sent to the laboratory when they are fresh and warm. DIF: Understanding REF: p. 1054

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed? a. Applesauce b. Orange Popsicle c. White toast d. Coffee with cream

ANS: D Coffee with cream should be avoided by patients recovering from gastroenteritis because milk proteins are difficult for the digestive system and caffeine is a diuretic, which can lead to continued dehydration. DIF: Understanding REF: p. 1057

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient's plan of care for the day before the test? a. Provide the patient with zinc oxide skin barrier cream for the perineal area. b. Obtain an order for a gentle laxative to be given once the test is completed. c. Carefully assess the patient's ability to swallow liquids through a straw. d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

ANS: A Complete bowel evacuation is required prior to colonoscopy so that the physician can visualize the interior of the large intestine. The patient will have multiple soft-liquid bowel movements as part of the bowel prep for the test, so skin barrier cream will be helpful to prevent perineal irritation. Laxatives will not be needed after the colonoscopy, and no contrast dyes are used. DIF: Applying REF: p. 1056

The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis of toileting self-care deficit? a. The patient will demonstrate safe transfer technique between wheelchair and toilet. b. The call light will be answered promptly when the patient needs to use the toilet. c. Toileting will be scheduled for the early morning when the patient needs to defecate. d. Toilet paper and hand-washing items will be kept within easy reach of the patient.

ANS: A The highest priority goal for this patient is the demonstration of safe transfer technique between the chair and the toilet. The other statements are interventions performed by staff rather than goals that will be accomplished by the patient. DIF: Applying REF: p. 1058

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority? a. Provide oral care after each episode of emesis. b. Apply a skin barrier to the patient's perineal area. c. Check the patient to see if he has a fecal impaction. d. Administer antiemetic medication with a sip of water.

ANS: C The patient who has abdominal pain and frequent small stools should be checked for fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the development of fecal impaction. The other actions can be performed once fecal impaction is ruled out. DIF: Applying REF: p. 1047 T

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient? a. Obtain an order to administer a soap suds cleansing enema. b. Teach the patient how to use the Valsalva maneuver. c. Discontinue medications that can cause constipation. d. Assess the patient's usual pattern of bowel movements.

ANS: D The nurse should assess the patient's usual pattern of bowel movements to determine if it is normal for the patient to have a bowel movement every 2 to 3 days. Elderly patients should be taught not to use the Valsalva maneuver because it can lead to bradycardia or death. DIF: Applying REF: p. 1047 | p. 1052

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement? a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema

ANS: D The patient with hard, dry stool in the rectum will benefit from an oil retention enema because it will soften the stool and make it easier to pass. Imodium is an antidiarrheal that will worsen the constipation. An oral fiber supplement and prune juice should be given after the patient has a bowel movement to prevent constipation from recurring. DIF: Applying REF: p. 1060

The nurse is caring for a patient who has diarrhea. What is the priority nursing diagnosis for this patient? a. Readiness for enhanced knowledge related to prescribed diet modifications b. Imbalanced nutrition: less than body requirements related to poor appetite c. Deficient fluid volume related to excessive loss of fluid through stool d. Anxiety related to incontinence with loose stools and need for clothing change

ANS: C Dehydration is the priority nursing problem for this patient, so deficient fluid volume is the most important nursing diagnosis. Imbalanced nutrition, Readiness for enhanced knowledge, and Anxiety can be addressed once fluid balance is restored. DIF: Applying REF: p. 1047

MULTIPLE CHOICE 1. The nurse is caring for a patient who periodically has small streaks of fresh red blood in his stool. The patient denies abdominal pain or loss of appetite. What is the most likely cause of this patient's bleeding? a. Hemorrhoids b. Bleeding gastric ulcer c. Colon polyps d. Perforated colon

ANS: A Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool. Bleeding gastric ulcer would lead to black, tarry stools as the blood is digested. Colon polyps do not cause bleeding. DIF: Understanding REF: p. 1046

The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Knowledge deficit r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

ANS: A The highest priority nursing diagnosis for this patient is impaired skin integrity because the liquid stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can lead to bacterial infection and significant discomfort for the patient. In addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing skin breakdown. DIF: Applying REF: p. 1055

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Keep the patient NPO and document the findings in the chart. b. Administer a laxative suppository to stimulate peristalsis. c. Insert a Salem sump nasogastric tube to low continuous suction. d. Notify the surgeon and prepare the patient to return to surgery.

ANS: A The presence of hypoactive bowel sounds is an expected finding for the first hours after abdominal surgery. The patient should be kept NPO to prevent nausea and vomiting. A laxative should not be administered. A nasogastric tube is not needed unless the patient starts vomiting or a paralytic ileus develops. DIF: Understanding REF: pp. 1051-1052 | p. 1055

MULTIPLE RESPONSE 1. The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions may the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth. b. Assessing the stoma and incision for signs of infection or ischemia. c. Obtaining needed supplies from the clean utility room. d. Teaching the patient how to care for the ostomy after discharge. e. Determining which type of ostomy appliance to use. f. Application of skin protectant to the area surrounding the stoma.

ANS: A, C, F The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain needed supplies, and apply skin protectant. The nurse is responsible for assessment, teaching, and determining which ostomy appliance to use. DIF: Applying REF: p. 1066

The nurse is caring for a patient who takes laxatives and enemas regularly to ensure that he has a large daily bowel movement. The patient states that he feels constipated if he does not defecate every day. Which nursing diagnosis is most appropriate for this patient? a. Health-seeking behaviors related to self-prescribed daily bowel regimen b. Perceived constipation related to professed need for daily laxatives c. Effective therapeutic regimen management related to defecation routine d. Disturbed thought processes related to obsession with daily bowel movements

ANS: B Perceived constipation is used when the patient self-diagnoses constipation and abuses laxatives to ensure daily bowel movements. This diagnosis best fits the patient's situation. The self-prescribed daily bowel regimen is not a health-seeking behavior because it is actually harmful to his health. His defecation routine is not an effective therapeutic regimen. The patient does not show evidence of disturbed thought processes. DIF: Applying REF: p. 1055

The nurse is caring for a patient with a history of dementia who is incontinent of stool because she cannot communicate the need to defecate. What is the priority action of the nurse? a. Administer a daily laxative and take the patient to the toilet afterward. b. Digitally remove stool from the patient's rectum every other day. c. Insert a rectal tube to facilitate drainage of soft or liquid stool. d. Begin a prompted toileting program to facilitate bowel continence.

ANS: D Patients who cannot communicate the need to use the toilet often benefit from a prompted toileting program in which the patient is brought to the toilet at the same times each day to promote urinary and bowel continence. A rectal tube should not be used. Digital disimpaction should be avoided whenever possible. Laxatives should be used only when absolutely necessary because continued use will lead to dependence. DIF: Applying REF: p. 1051 | pp. 1055-1056