Chp 38 PrepU Bowel Elimination

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."

When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client?

"Do you frequently take antacids?"

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

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

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 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."

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."

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

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

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."

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

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care."

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 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 remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply. -Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. -Instruct client to bear down, if possible, while extracting feces to ease in removal. -Insert gloved finger gently into anal canal, pointing toward the umbilicus. -Generously lubricate index finger of dominant hand with water-soluble lubricant. -Put on sterile gloves.

-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 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

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 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.

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

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 (7.5cm)

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

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

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.

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

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.

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? -Attempt to irrigate the NG tube with water or normal saline. - Remove the NG tube and replace it with a larger-bore tube, as ordered. -Instill digestive enzymes, as ordered. -Turn off the suction for 30 minutes and then turn it on again.

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

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

Avoid more than 250 mg

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

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 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 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 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 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

Which symptom is a known side effect of antibiotics?

Diarrhea

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

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

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?"

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 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 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

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 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.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?

Hyperactive bowel sounds

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

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

The 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

The nurse prepares to collect the client's stool for ova and parasites. Which actions should the nurse provide? Select all that apply.

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

Which medication causes constipation?

Iron supplements

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

Left lateral

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?

Lower solution container and check temperature and flow rate.

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 needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?

Oil-retention

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.

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

Refrain from eating red meat 3 days before testing.

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse? -Inform the client that the culture prescription will now be cancelled. -Reinstruct the client on use of collection container for next bowel movement. -Collect stool and send to laboratory for culture per regular protocol. -Administer a PRN dose of laxative to the client to collect new sample.

Reinstruct the client on use of collection container for next bowel movement.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply. -"Is the stool difficult to pass?" -"Do you use laxatives?" -"What are your normal bowel habits?" -"Have you started a new medication?" -"Are you experiencing rectal fullness?"

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

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

Stop the administration of the enema momentarily.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure.

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 client is experiencing a vasovagal reaction. -The NG tube is curled in the back of the client's throat. -The client is forcefully resisting the procedure. -The NG tube is in the client's airway.

The NG tube is in the client's airway.

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.

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

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 educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? -rice -lettuce -brussels sprouts -green peppers

Weakened pelvic muscles lead to constipation.

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

Wearing disposable gloves

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

Yogurt and buttermilk

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

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

Which procedures can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.

administration of enemas until clear administration of a large-volume enema administration of a small-volume enema application of a fecal incontinence device

The proliferation of Clostridium difficile causes:

antibiotic associated diarrhea

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? -prone -right side-lying -supine -left side-lying

auscultation.

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

black clay colored yellow

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 has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply. -"The client uses spray deodorant several times an hour to mask odor." -"The client makes neutral or positive statements about the ostomy." -"The client expresses interest in learning self-care." -"The client agrees to take prescribed antidepressants." -"The client is willing to look at the stoma."

brussels sprouts

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

cecum

A client is not having a bowel movement daily. The client perceives being constipated. Which assessment data is the nurse likely to collect from this client? Select all that apply.

chronic purging using laxatives several times daily

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

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

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

false

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 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

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

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

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

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

left side-lying

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

lentils onions cabbage

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

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

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

past the internal sphincter

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

peptic ulcer

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? -Fish and dried lentils -Onions and garlic -Asparagus and turnip -Yogurt and buttermilk

physiologic or lifestyle changes in the client.

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

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

secondary constipation

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

sigmoid colostomy

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

sims

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds

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