Chapter 38: Bowel Elimination

The nurse has educated a client regarding an upcoming wireless video capsule endoscopy. What statement made by the client indicates that the client needs further education related to the procedure?

"The tablet will be absorbed and not excreted."

Which statement about ostomy irrigation is true?

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination.

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.

The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client?

Keep the client's bed in the lowest position. Diphenoxylate and atropine may cause drowsiness, so the client is at risk for falls. The bed should be kept in its lowest position. Clients should avoid foods such as fresh fruits and vegetables as these foods are high in fiber; this client needs a low-fiber diet. Diphenoxylate and atropine should be discontinued if it has no effect on the diarrhea in 48 hours. Diphenoxylate and atropine do not contain aspirin, so the nurse need not check with the health care provider before administering.

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

Left lateral

A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation?

Lower the solution container and check the temperature and flow rate.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation?

Lower the solution container and check the temperature and flow rate.

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

A nurse assesses a client who has a PRN (as-needed) prescription for a small-volume cleansing enema. What result would contraindicate the safe administration of an enema? Select all that apply.

Platelet count of 19,500/mm3 (195.00 ×109/L) Anal fissures A platelet count of less than 20,000/mL (20.00 ×109/L) may seriously compromise the client's ability to clot blood. An enema would therefore create a risk for hemorrhage. The presence of an anal fissure would similarly contraindicate an enema due to the risk for trauma, infection, and bleeding. The client's hemoglobin is normal and a slightly increased white cell count does not contraindicate the use of an enema. Clients with diabetes can safely receive enemas.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

Sims

The nurse is assessing a client who reports being constipated. Which assessment data confirm the client report? Select all that apply.

The client has a distended, hard abdomen. The client reports fullness in the rectum.

The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which interventions are appropriate suggestions? Select all that apply.

Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. Apply a commercially available skin barrier before applying the ostomy pouch.

A client diagnosed with colorectal cancer reports constipation to the nurse. Which teaching will the nurse provide to help the client identify sign(s) or symptom(s) of constipation? Select all that apply. You Selected:

Watch for liquid bowel movements after days with none. You will urinate less often or not at all. You may experience pain on defecation.

A client with constipation has been instructed to increase the intake of foods high in fluid. Which food(s) will the nurse include in the client's education? Select all that apply.

Watermelon Strawberries Cantaloupe Lettuce Cucumber

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

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

Wearing disposable gloves

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?

Whole wheat spaghetti and broccoli

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery Digital removal of stool should not be performed on clients who have bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. None of the other listed health problems contraindicate digital removal of stool.

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation?

affects absorption of fat-soluble vitamins

The proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea.

The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education?

"I will have a fecal occult blood test done every 5 years." Yearly screenings, including a fecal occult blood test, should be done on all clients over the age of 50. A flexible endoscopic exam should be done every 5 years. A family history of colorectal cancer increases the risk of developing colorectal cancer.

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

"Only if the stool has not been contaminated by urine."

In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet?

20-30 g

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

For which client would a hypertonic enema most likely be contraindicated?

A client with renal impairment

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?

briefly clamping the tubing while the client breathes deeply

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information?

Auscultate for bowel sounds.

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 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.

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag?

Baked beans

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 reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? Select all that apply.

cucumbers lentils onions cabbage

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding?

secondary constipation The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition.

A client is prescribed a large volume cleansing enema and is concerned as to why the large volume is indicated. What response should the nurse give to the client? Select all that apply.

to relieve constipation to prevent involuntary escape of fecal material during surgical procedures to promote optimal visualization of the colon during a colonoscopy

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. A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.

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 doing preoperative teaching with a client who has a prescription for Golytely® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner?

Chilled

The nurse is teaching a client with diarrhea about dietary management. Which teaching will the nurse include? Select all that apply.

Choose bland foods, such as cottage cheese. Bananas and applesauce are appropriate.

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.

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.

A client is reporting increased flatulence which is causing great embarrassment. When creating a plan of care for this client, what interventions will be most helpful to the client to control the excess flatulence. Select all that apply.

Encourage the client to limit the intake of carbonated beverages. Provide smoking cessation education and literature Encourage the client to avoid the use of straws when drinking liquid Inform the client that eating slowly and chewing food well can reduce the incidence of flatulence

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?

Every 4 to 8 hours

A nurse is caring for a client who has a large, hardened mass of stool that is interfering with defecation, making it impossible for the client to pass feces voluntarily. Which recommendation(s) will the nurse provide the client to prevent future fecal impaction from occurring? Select all that apply.

Increasing fluid intake Increasing daytime exercise

A nurse is conducting an abdominal assessment. Which palpation finding(s) necessitates reporting to the health care provider? Select all that apply.

Mass lower left quadrant Distention Firmness Abdominal crepitus Rebound tenderness

The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. The nurse would intervene if which food item is included on the client's tray?

Sliced red apples

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway.

When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply.

Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water.

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

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather?

tap water

The nurse is preparing to administer a hypertonic saline enema. How much should the nurse prepare to administer?

120 mL

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply.

lentils onions cabbage

The nurse is reviewing prescriptions to irrigate an ostomy. Which clients can have their ostomy irrigated? Select all that apply.

A client with a left-sided end colostomy A client with a sigmoid colostomy

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. Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

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. To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe. If a Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.

A nurse who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply.

Clients who are constipated should eat more fruits and vegetables. Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. Clients with food intolerances may experience altered bowel elimination.

A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply.

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test

The nurse is irrigating a nasogastric tube attached to suction and finds that the flush solution is meeting a lot of force when the plunger is pushed. What would be the nurse's first intervention in this situation?

Inject 20 to 30 mL of free air into the abdomen in attempt to reposition the tube and enable flushing of the tube.

The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply.

Insert gloved finger gently into anal canal, pointing toward the umbilicus. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

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?

Make sure that the appliance is not cut too large. The priority action of the nurse would be to assess the situation to determine the possible cause. This will involve making 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. if the fecal material is outside the bag, then the bag was not applied correctly and it leaked. 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 should complete the assessment before notifying the health care provider to be able to provide the health care provider with enough information to make an appropriate decision.

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

Peptic Ulcer Any health problem that involves bleeding of the GI tract, such as peptic ulcer disease, may require fecal occult blood testing (FOBT). Constipation does not indicate a need for FOBT unless hardened stool is suspected of causing GI trauma. Similarly, GERD may require FOBT only if esophageal bleeding is suspected. Liver disease is not a common indication for FOBT.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows.

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 health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply.

The client has a history of chronic renal failure. The client has an elevated phosphorus level. The client has a history of left sided heart failure.

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply.

The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The client should be instructed not to place toilet tissue in the bedpan or specimen container. Medical aseptic techniques are always followed. Handwashing is performed before and after glove use when handling a stool specimen.

The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply.

"Movement of the colon is stimulated by the parasympathetic nervous system." "The last part of the large intestine is the rectum, not the anus." "The stool becomes hard if it remains in the large intestine too long." The rectum is the last part of the large intestine. Water is absorbed while the stool is in the large intestine; therefore, the longer it remains there, the harder it becomes. The parasympathetic nervous system stimulates the colon. Vitamin K and some of the B-complex vitamins are produced by bacterial action in the large intestine. The nervous system innervates the muscles of the colon.

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly? Select all that apply.

The nurse administers the oil-retention enema at body temperature. The nurse instructs the client to retain the oil for at least 30 minutes. The nurse administers a cleansing enema after the oil-retention enema.

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. true or false

false

A nurse is performing a physical assessment on a client with gastrointestinal distress. Which assessment(s) should the nurse perform? Select all that apply.

Inspect the abdomen for symmetry Auscultate bowel sounds for regularity Percuss the abdomen for tympany Palpate the abdomen for distention

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order.

Inspection Auscultation Percussion Palpation

Which medication causes constipation?

Iron supplements

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 water and mild soap.

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 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?

Yogurt and buttermilk

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.

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."

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."

The nurse is providing education for a client with frequent constipation about the use of bisacodyl to improve defecation. What statements made by the client indicate that the teaching is effective? Select all that apply.

"Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." "It will improve defecation by increasing motility." "I should increase my fluid intake to help with my bowel movements.

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus?

"Certain vegetables can cause flatus, as they are more difficult to digest."

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply.

"Do you use anything to help move your bowels?" "How often do you move your bowels?"

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 conducting teaching with a client who has a prescription for a wireless capsule endoscopy. Which statement by the client would indicate to the nurse that the teaching was effective?

"I can go about my daily routine while the camera is passing though my small intestine."

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?

"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.

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."

The nurse has provided a client with supplies for a fecal immunochemical test (FIT). Which client statement reflects understanding of the purpose of this test?

"This test can help indicate if I have colorectal cancer."

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."

A client has been given fecal immunochemical test (FIT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test, if positive, will indicate bleeding in the lower gastrointestinal tract."

The nurse has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse?

"Wait to do the test 3 days after your finish menstruating."

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

dark brown light brown

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 health care provider. 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

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema?

draws fluid from body tissues into the bowel

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply

hot tea with meals a turkey sandwich with whole-grain bread prune juice with breakfast

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be:

yellow.

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 nurse is administering a client's large-volume enema. What assessment finding would indicate to the nurse that the solution is being administered too quickly?

Decrease in heart rate

Which symptom is a known side effect of antibiotics?

Diarrhea

A paraplegic man receives care in the rehabilitation facility. He confides in a nurse that he has trouble controlling his bowel movements. He tends to normally stool 6 to 8 times per day. This has caused the skin around his rectum to become irritated. Which is not an appropriate NANDA-I diagnosis for this client?

Diarrhea r/t decreased muscle tone and sphincter control

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 client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take?

Facilitate a more private setting, such as assisting the client to a bathroom.

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces

False

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.

False

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure?

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching?

Grapefruit

A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding?

Have the client rest for half an hour and then reassess.

Which principle should guide the nurse's collection of a fecal occult blood test?

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period.

The nurse is selecting antidiarrheal medications for clients with diarrhea. Which statements accurately describe the action of specific antidiarrheal medications? Select all that apply.

Loperamide is a nonaddictive antidiarrheal medication that has a longer duration of action than diphenoxylate/atropine. Bismuth subsalicylate contains salicylates; a physician should be consulted before giving it to children or clients taking aspirin. Paregoric contains morphine and may be addictive.

A nurse is assessing the stoma of a client who had an ostomy. Which assessment finding(s) necessitates further evaluation of the stoma? Select all that apply.

Pallor of the stoma Purple-blue color of the stoma Irritation and dryness at the stoma site Yellow discharge at the stoma site Bleeding at the stoma site

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

Perform a screening test on stool samples. The nurse should independently perform a screening test on the stool samples to determine the presence of blood. Once the nurse confirms the presence of blood, the nurse can keep the stool sample in a covered container and then report to the physician. The nurse does not send the stool sample to the laboratory because it is the physician who may order more specific laboratory or diagnostic tests. Immediate action is required and should not be postponed until it can happen again.

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply.

Place the client in a side-lying position. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. Provide a sitz bath or tub bath after the procedure to soothe the perianal area

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

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.

The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed?

Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate When removing the appliance, the nurse should start at the top, not bottom, to prevent spillage of intestinal content. The disposal pad protects the work surface. Emptying the appliance before removal prevents spillage of fecal material. The skin should dry completely to provide good adherence of the appliance; applying a protectant to a 2-in (5-cm) radius around the stoma provides protection to the skin and prevents breakdown.

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.

The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply.

The autonomic nervous system innervates the muscles of the colon. Peristalsis occurs every 3 to 12 minutes. Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people. Mass peristalsis often occurs after food has been ingested.

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor?

The client takes bisacodyl every day.

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.

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

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 health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

removes hardened fecal impactions from the rectum Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.

A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation?

tap water and normal saline solution Tap water and normal saline solution is preferred for cleansing the bowel in preparation for a rectal examination because of its non-irritating effects. A combination of tap water and soap solution is not suitable because soap causes chemical irritation of the mucous membranes. A concentrated hypertonic saline solution also acts as a local irritant on the mucous membranes. Cottonseed or olive oil solution is also not suitable because the oil solution is held within the large intestine, and if the client has premature defecation, it could defeat the purpose of retention.

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate?

"Irrigating the colostomy can help establish an elimination routine." Irrigations are used to promote regular evacuation of some colostomies. Left-sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.

The nurse is performing a health history for a client who presents to the clinic with abdominal discomfort. Which statements made by the client indicate that the client is at risk for the development of constipation? Select all that apply

"Sometimes I don't have the opportunity to defecate when I need to while I am at work." "I drink about 16 ounces of fluids a day." "I don't like to exercise because I am tired all of the time."

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 replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action?

A risk that the peristomal skin will become excoriated An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next?

Apply skin barrier to the tip and end of the nose. Skin barrier improves adhesion and protects the skin. Applying the skin barrier should occur before taping the tube to the client's nose, measuring the length of exposed tube, or lubricating the lips.

The nurse is caring for a client who requires a cleansing enema before undergoing an x-ray of the bowel. When planning and implementing this intervention, which action(s) will the nurse take? Select all that apply.

Auscultate the bowel sounds. Ensure there is a bedpan at the bedside. Place the client in a Sims position.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing the tube, discontinue suction and separate the tube from suction When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath.

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

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 food poisoning

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.

The nurse is administering magnesium citrate to a client with constipation. What mechanism of action would the nurse expect from this drug?

Drawing water into the intestines to stimulate peristalsis

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 Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70 to 130 ml). These solutions draw water into the colon, which stimulates the defecation reflex. Oil retention enemas lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 ml of solution is administered to adults.

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply.

Help the client into a Sims' position. Compress the container as the solution instills. Encourage the client to retain the solution.

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client?

History of facial fractures

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

If you have had a recent nose bleed, postpone using test. When educating a client about using the at home fecal occult blood test (FOBT), the nurse instructs the client to not use laxatives or enemas, postpone if female is menstruating, postpone if hematuria, bleeding hemorrhoids, or blood nose recently. Drinking orange juice can cause false negative results.

The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema?

Platelet count of 18,000/mm3

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

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago.

A nurse prepares to collect a stool sample from a client to test for fecal fat. Which guideline accurately describes a consideration in this process?

The entire amount of stool produced for 24 to 72 hours should be sent to the laboratory For a timed stool test, such as fecal fat, the entire amount of stool produced for 24 to 72 hours is sent to the laboratory. In the cases of a room temperature sample or the presence of toilet paper, the nurse should call the laboratory to discuss possible effects on test results. Stool can be collected from an incontinent brief or diaper as long as it has not been contaminated by urine.

A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply.

The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.

The nurse places the client in the supine position with the abdomen exposed. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.

The nurse assesses the stool of clients admitted to the hospital with abdominal distress. Which statements accurately describe the normal characteristics of stool and special considerations for observation? Select all that apply.

The rapid rate of peristalsis in the breastfed infant causes the stool to be yellow. Antacids in the diet cause the stool to be whitish. A gastrointestinal obstruction may result in a narrow, pencil-shaped stool.

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 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 nurse is teaching a client how to change his ostomy appliance. Which instructions should be incorporated into the teaching plan?

Use toilet tissue to remove any excess stool from the stoma. Excess stool may be removed from the stoma using toilet paper. The pouch faceplate should be removed from the skin by pushing, rather than pulling, the skin from the appliance. If reusable, the appliance should be washed in lukewarm soap and water. Skin protectant should be applied to a 2-in (5 cm) radius around the stoma and allowed to air dry about 30 seconds

The student nurse is preparing a presentation on bowel elimination. Which potential cause(s) of diarrhea will the student include? Select all that apply.

antibiotics acute stress depression

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

cecum

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?

sigmoid colostomy

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 Be gentle and lubricate the tip generously before insertion of the enema, but a hemorrhoid is not a reason to stop. When a client experiences dizziness, light-headedness, and sweating, the nurse should slow down the administration of the enema and ask the client to take slow, deep breaths and relax to decrease the symptoms of rapid administration and vagal response. The nurse should stop the enemas with severe abdominal pain, assess bowel sounds, and call the primary care provider because the pain may be a warning sign of trauma to the GI tract or potential perforation of the bowel. It is an expected finding that the enema will stimulate peristalsis.

A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.

weak abdominal muscles severe dehydration unrelieved constipation

A client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply.

whether the client is taking new medication the client's normal bowel habits if the client feels a sensation of rectal fullness if the client has used laxatives in the past