Module 15: Bowel Elimination

The nurse has finished installing a small-volume cleansing enema into a client. What instructions owuld the nurse give the client following the installation?

"Hold the solution in until the need to defecate is strong."

The client asks to help express the small-volume enema solution. Which instructions by the nurse will best facilitate instilling the enema solution completely?

"Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum."

The nurse is administering a large-volume enema to treat a patient's constipation following abdominal surgery. After checking the enema device for defects, what would be the nurse's first step?

Add the enema solution and any additives to the enema bag

Which would be most appropriate for the nurse to do when removing the NG tube?

Ask the client to take a deep breath and pull out the tube quickly and carefully.

The healthcare provider has written a prescription for a clients NG tube to be removed. Which would the nurse do first?

Discontinue the suction.

In what position with the nurse for the surge when instilling irrigation solution into the NG tube?

Downward at a 90-degree angle.

In what position would the nurse placed the client prior to removing a NG tube?

In an upright position with the bedrail nearest the nurse down.

The nurse is not successful in attempting to irrigate an NG tube. The nursery repositions the clients and tries to flush the tube with air and water multiple times without success. What action does the nurse take next?

Notify the health care provider.

The nurses irrigating an NG tube connected to suction for a client undergoing a gastric decompression and meet resistance after attaching the irrigation syringe to the NG tube. Which would be most appropriate for the nurse to do first?

Reposition the client and try again.

After inserting the NG tube, what should the nurse due to insure that the tube is properly placed in the clients

Test the pH of aspirated content.

The nurses taught client how to change the ostomy back. How would the clamp be placed to demonstrate that the client understood the directions?

The curve of the clamp would follow the curve of the client's body.

The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene?

client cuts the opening on the new bag 0.5 in (1.25cm) larger than the stoma size.

The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing another closing clamp?

upward

The nurse is preparing to irrigate a client's NG tube. Which would the nurse include on teaching a client about this procedure?

"You may feel cold solution going down your throat, but it should not hurt."

The nurse is preparing to empty an open-ended colostomy pouch. Place in order of the steps the nurse would take. Use all options.

1. Fold the end of the pouch upward like a cuff. 2. Empty the contents into a measuring device. 3. Wipe the lower 2in (5cm) of the pouch with toilet tissue. 4. Uncuff the edge of the pouch. 5. Apply the clamp.

Place in order the steps the nurse should take if a client reports cramping and bloating during enema administration. Use all options.

1. Stop administration if the client reports severe cramping and bloating. 2. Encourage the client to take short, panting breaths until the cramping subsides. 3. Administer the enema slowly at a height less than 18 in (0.5 m) above the client. 4. Discontinue the procedure and notify the healthcare provider if pain occurs.

The nurse is administering a large-volume cleansing enema. After stopping the enema, which instructions should the nurse provide if the client reports severe pain and bloating?

Breathe out in short, panting breaths.

The nurse is following the protocol for irrigating a the client's NG tube. Before attaching the syringe to irrigate the tube, which action would be most important for the nurse to do?

Check tube placement.

The nurse has completed irrigation of a NG tube connected to suction. Which step would the nurse perform following the injection of irrigation solution into a client's NG tube?

Connect the unclamped NG tube back to the suction unit.

After moving the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance?

Fold the end of the pouch upward, like a cuff

Following the removal of a NG tube, the nurse should monitor the client for which possible adverse reaction?

Gastric distention.

While changing the ostomy appliance of a client with a colostomy, the nurse finds significant bleeding around the area of the stoma. What would be the recommended nursing action after notifying t the provider?

Gently pat the area dry and apply the new appliance when the skin is completely dry.

When irrigating an NG tube, the nurse does not get a return after instilling irrigation solution and reconnecting the tube back to the suction unit. What would be the nurse's next step in the situation?

Instill 20mL of air into the tube and aspirate again.

The nurse is administering a large-volume cleansing enema to a patient undergoing bowel surgery. Which of the following tips might the nurse share with the student nurse assisting with the procedure?

Lubricate the tip of the rectal tube for easy insertion

The nurse is monitoring a client who had a NG tube placed postoperatively after abdominal surgery. Which criterion with the nurse use to determine to the tube could be removed?

Passage of flatus.

The nurse has begun inserting the NG tube when the client coughs after assessing that the client can speak without difficulty, what should the nurse to next

Proceed with NG tube placement.

The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube? a. Insert tube 3 to 4 in (7.5 to 10cm) and angle toward the naval. b. Insert tube 3 to 4 in (7.5 to 10cm) and angle toward the bladder. c. Insert tube 1 to 2 in (2.5 to 5 cm) and angle toward the bladder. d. Insert tube 1 to 2 in (2.5 to 5 cm) and angle toward the naval.

a. Insert tube 3 to 4 in (7.5 to 10cm) and angle toward the naval.

A nurse is administering a small - volume enema to a clients to the fecal impaction. After initiating this action, the client reports nausea and lightheadedness. The nurse also notice a decrease in the clients heart rate. What should the nurse to first?

a. stop the procedure and monitor the client's heart rate

The nurse is assisting the client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform independently?

after performing the first appliance change, observe the client performing the next change.

Which nursing assessment takes priority when administering an enema to a client? a. Anxiety b. dizziness c. elevated respiratory rate d. headache

b. dizziness The enema may stimulate a vagal response, which increases parasympathetic stimulation.

The nurse is collecting supplies to change the ostomy appliance of a client who has ileostomy following surgery for a tumor. What items with the nurse prepare to wash around the stoma?

basin of warm water

The nurse is preparing a client to administer a small-volume cleansing enema. In what position would the nurse place the client for this procedure? a. lying supine, with the knees bent and the bottom of the bed slightly raised b. lying on the right side with the head of the bed slightly raised c. lying on the left side with the bed flat and the back of client facing the nurse d. lying in the prone position, flat on the bed

c. lying on the left side with the bed flat and the back of client facing the nurse

The nurse is monitoring the clients with a colostomy and notices that the ostomy appliance is leaking. What would be the appropriate nursing action in this situation?

change the appliance immediately

A nurse aspirate fluid through a client's nasal gastric tube and checks the fluid for color and consistency. Which is a normal finding suggesting correct gastric placement of the tube?

green color with particles

Which documentation does the nurse complete after inserting a clients NG tube?

measurement of the exposed tube

When changing the clients ostomy appliance, the nurse finds that feces continue to flow around the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs?

place a piece of gauze over the stoma to absorb the drainage.

Following insertion of a neat NG tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take?

secure the tubing with a safety pin to the client's gown at shoulder level.

The nurses is emptying an ostomy appliance for a client on bedrest. In what position would the nurse place the client for this procedure?

sitting

After measuring from the clients nostril to the air lobe, how does the nurse continue to measure the length of the nasogastric tube to be inserted for a client?

to the xiphoid process

The nurse is teaching a client how to empty an ostomy appliance. How often with the nurse recommend the appliance be emptied?

when bag is one-third to one-half full