Chapter 35 Bowel Elimination PrepU

A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?

Insert a lubricated, gloved finger into the rectum.

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document?

"Ileostomy bag half filled with liquid feces."

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 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."

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)

The nurse is checking the placement of a nasogastric tube and aspirates for gastric contents. The nurse checks the pH of the aspirate and determines that the tube is in the stomach when she gets which pH measurement?

5

The nurse is caring for a client with a stoma that is pink in color and dry. Which action will the nurse take?

Apply petroleum-based ointment.

A nurse is providing home care for a middle-aged client with fecal incontinence. Friends have come to visit the client, but the client avoids meeting with them. Which action can the nurse take to best address the client's avoidance behavior?

Ask open-ended questions to elicit why the client is avoiding friends.

ATI: A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood

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.

The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client?

Constipation

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.

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

Digital removal of stool may cause parasympathetic stimulation.

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.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Habitual laxative use is the most common cause of chronic constipation.

ATI: A nurse is preparing to administer a cleansing enema to a client. Which of the following actions will the nurse take?

Hold the container of solution 30 cm (12 in) above the anus.

ATI: A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables

A client with terminal cancer is taking high doses of a narcotic for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

Increase fiber in the diet.

The nurse is preparing to insert a nasogastric tube for a client needing decompression. Which method would be most appropriate for the nurse to use to determine the length of tubing to be inserted?

Measure from the tip of earlobe to tip of nose to the tip of xiphoid process.

A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?

Monitor for rectal bleeding.

ATI: A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

Nonantimicrobial soap

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, ten 8-oz glasses (2,500 mL) of fluids. What would the nurse tell the client to change?

Nothing; this is a good diet.

ATI: A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients

ATI: A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Palpates the abdomen prior to performing auscultation

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

Palpation inspection, auscultation, percussion, palpation.

ATI: A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?

Rotate the catheter tip inside the stoma.

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next?

Shower, bathe, or wash peristomal area with mild soapy water.

ATI: A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Slow the flow of enema solution briefly

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

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

ATI: A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a nasogastric (NG) tube to suction.

A nurse is preparing a client for colon surgery. Which teaching should the nurse provide first to prepare the client for what to expect after surgery?

The nurse will listen to the bowel sounds regularly.

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?

The position does not facilitate downward pressure.

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of statement describes this condition?

The stoma is protruding into the bag and may become twisted

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. The nurse is teaching the mother about infant care. What are characteristics of the stool the nurse would expect to assess and teach the mother in breast-fed infants?

The stool will be yellow to golden and loose.

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.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk?

Wearing disposable gloves

ATI: A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

When the client has the urge to defecate

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

brown rice

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

inadequate intake of liquid

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?

increased bowel sounds

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds."

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."

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?"

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 has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

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

ATI: A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? SATA

-BID -30 mL

An older adult client has a history of constipation and currently self-treats with over-the-counter laxatives. What education will the nurse provide the client regarding the use of laxatives? Select all that apply.

-Oral laxatives take longer to work than laxatives administered rectally. -Older adults are at a higher risk for laxative misuse and abuse. -Rectal suppositories need to be retained in the rectum for at least 15 minutes. -Incorporate high-fiber foods into the diet and increase fluid intake.

The nurse is educating a parent who has called the clinic reporting the child is experiencing diarrhea. What suggestions should the nurse provide to the parent? Select all that apply.

-Provide a diet high in complex carbohydrates, meats, fruits, and vegetables -Replace fluids that have sodium chloride, potassium, and glucose -Assume an age appropriate diet when possible

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

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

-light brown -dark brown

The nurse is preparing a client for a guaiac fecal occult blood test. What medication(s) taken by the client may cause a false-positive result in the test? Select all that apply.

-warfarin 10 mg daily -acetylsalicylic acid 80 mg daily -ibuprofen 400 mg daily

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

-yellow -black -clay colored

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

50-year-old client with a family history of polyps

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.

ATI: A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position

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 nurse is providing discharge instructions for a client with a new colostomy. Which is a recommended guideline for long-term ostomy care?

Drink at least 2 quarts (1.9 L) of fluids, preferably water, daily.

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.

ATI: A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? SATA

Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake

A nurse is scheduling diagnostic studies for a client. Which test would be performed first?

Fecal occult blood test

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. Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas.

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

Peptic Ulcer

Which client is most likely to require interventions in order to maintain regular bowel patterns?

a client whose neuropathic pain requires multiple doses of opioids each day

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

auscultation

What is fecal occult blood?

blood that cannot be seen

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

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?

cleansing enema

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

dark pink and moist

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 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

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

oil

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

A nurse is caring for a 65-year-old woman who has undergone a hernia operation. The client receives morphine via patient-controlled anesthesia for postoperative pain. The client also receives sulfamethoxazole-trimethoprim every 12 hours to treat a urinary tract infection, and an iron supplement for anemia. The client is on mobility restrictions because of the narcotics. The client explains that while she usually passes stool once per day, she has passed stool four times today. The health care provider has diagnosed diarrhea. What is most likely contributing to this outcome?

sulfamethoxazole-trimethoprim

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider?

the client who experiences severe abdominal pain

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