Taylor Chapter 37 review questions- Bowel Elimination

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

Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Explanation: If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

The nurse understands that which client diversion is considered a continent ostomy? A. Ileostomy B. Ileoanal C. Ileal conduit D. Colostomy

Ileoanal Explanation: A continent fecal diversion is the ileoanal diversion. With this type of diversion, feces can be drained at the client's convenience rather than having it continually draining into an external pouch, as occurs in the traditional ileostomy or colostomy.

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 Explanation: The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

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? A. "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." B. "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." C. "That's correct, but be sure that you don't increase your laxative doses over time." D. "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives."

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." Explanation: Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

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

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins." Explanation: The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment, and determine other appropriate interventions to relieve constipation.

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? A. "The capsule I have to swallow is no larger than a vitamin tablet." B. "I will be wearing a belt with the wires and a recorder." C. "The tablet will be absorbed and not excreted." D. "I will return after 8 hours to have the sensors and data recorder removed."

"The tablet will be absorbed and not excreted." Explanation: The client swallows a capsule, about the size of a vitamin, which contains a small camera that emits a radio signal. Several wires on the patient's abdomen pick up the radio signal from the capsule, and the data are recorded on a data recorder, which the patient wears on a belt. The system captures about 55,000 images in an 8-hour exam. The patient returns to the facility after 8 hours, and the external sensors and data recorder are removed. The capsule is excreted during the process of normal defecation in 24 to 48 hours and is intended for one-time use only

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? A. 60-70 g B. >80g C. 20-30 g D. 40-50 g

20-30 g Explanation: A person who consumes approximately 20 to 30 grams of dietary fiber from fruits, vegetables, and grains will most likely have sufficient bulk in the stools to allow for easy defecation.

Which client is most likely to require interventions in order to maintain regular bowel patterns? A. A client whose neuropathic pain requires multiple doses of opioids each day. B. A client who has a history of atrial fibrillation requiring daily anticoagulants. C. A client with hypertension who takes a diuretic and adrenergic blocker each morning. D. A woman 59 years of age who has recently begun hormone replacement therapy.

A client whose neuropathic pain requires multiple doses of opioids each day. Explanation: Opioids have a very high potential to cause constipation. Anticoagulants, hormone replacements, diuretics, and adrenergic blockers are not among the medications commonly implicated in cases of constipation.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C 3 days before testing? A. Drink orange and grapefruit juice. B. Take 500 mg. C. Avoid more than 250 mg. D. Consume citrus fruits.

Avoid more than 250 mg. Explanation: The nurse will teach the client to avoid taking more than 250 mg of vitamin C 2 to 3 days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action? A. Clamp the tube for a brief period and resume at a slower rate. B. Continue infusing at a faster rate to finish the enema quicker. C. Discontinue the administration of the enema D. Remove the tubing.

Clamp the tube for a brief period and resume at a slower rate. Explanation: Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

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? A. Carminative enema B. Return-flow enema C. Retention enema D. Cleansing enema

Cleansing enema Explanation: The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction; promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy); establish regular bowel function; and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.

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? A. Dark pink and moist. B. Off-white or pale pink. C. Dark or purple-blue. D. Red and dry.

Dark pink and moist. Explanation: A healthy stoma is dark pink to red and moist. Redness is normal as well as moisture to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? A. Most clients will not consent to have digital removal of stool. B. It often causes rebound diarrhea and electrolyte loss. C. Nurses find the procedure distasteful and difficult to perform. D. Digital removal of stool may cause parasympathetic stimulation.

Digital removal of stool may cause parasympathetic stimulation. Explanation: The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

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

False Explanation: A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag?

Formed Explanation: A colostomy is an opening of the large intestine that allows formed feces from the colon to exit through the stoma.

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? A. Hyperactive bowel sounds B. Visible waves of abdominal peristalsis C. Increased anal area pigmentation D. Dry, hard stool

Hyperactive bowel sounds Explanation: Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.

Which medication causes constipation?

Iron supplements Explanation: A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.

The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client? A. Encourage the client to eat fresh fruits and vegetables. B. If diarrhea is still present after 48 hours, continue giving diphenoxylate and atropine. C. Keep the client's bed in the lowest position. D. Check with health care provider before giving diphenoxylate and atropine to a child.

Keep the client's bed in the lowest position. Explanation: 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.

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? A. Right side-lying B. Supine C. Left side-lying D. Prone

Left side-lying Explanation: When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client not for an enema.

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. Explanation: The nurse's next action would be to lower the solution container and check the temperature and flow rate. Lowering the solution container decreases the pressure of the flow of the solution. The cramping could be related to the pressure of the flow, the temperature of the solution, or a high flow rate of the solution. The nurse would not place the client in a supine position, but in a low-Fowler's position or higher. The nurse would not remove the tube and check for any fecal contents. The nurse would not modify the amount and length of the administration, as this is not causing the severe cramping.

Which enema solution lubricates the stool and intestinal mucosa without distending the intestine? A. Water B. Oil C. Normal saline D. Soap

Oil Explanation: Mineral, olive, or cottonseed oil are used to lubricate the stool and intestinal mucosa without distending the intestine. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. Soap suds enema (SSE) is a hypertonic solution that provides a large-volume and detergent-based mucosal irritation to draw water into the colon, which stimulates the defecation reflex.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? A. Peptic Ulcer B. Cirrhosis of the Liver C. Chronic Constipation D. Gastroesophageal Reflux Disease (GERD)

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

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Explanation: The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? A. Slow the infusion rate, have the client take deep breaths, then resume the enema. B. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. C. Stop the procedure, monitor heart rate and blood pressure. D. Stop the procedure and reposition the client.

Stop the procedure, monitor heart rate and blood pressure. Explanation: When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response.

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? A. Clean it with a dry, cotton bandage. B. Avoid using commercial skin preparations. C. Avoid applying a barrier substance. D. Wash it with a mild cleanser and water.

Wash it with a mild cleanser and water. Explanation: Washing the stoma and surrounding skin with a mild cleanser and water, and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering. Another way to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.

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? A. Yogurt and buttermilk B. Fish and dried lentils C. Onions and garlic D. Asparagus and turnip

Yogurt and buttermilk Explanation: Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.

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: A. light palpation. B. percussion. C. auscultation. D. deep palpation.

auscultation. Explanation: When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.

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 Explanation: The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to: A. blue. B. green. C. red. D. brown.

blue. Explanation: Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.

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

cecum Explanation: The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.

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 Explanation: The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan), and yellow are considered abnormal colors for adult stool.

An older adult client who is wheelchair bound following a cerebrovascular accident is being assessed by the nurse. The nurse notes the client has seepage of stool from the anus. What does the nurse identify may be the clients condition? A. constipation. B. fecal impaction. C. intestinal infection. D. diarrhea.

fecal impaction. Explanation: The nurse should suspect a fecal impaction when there is a history of absence of a regular bowel movement for several days (3-5 days or more), followed by the passage of liquid or semi-liquid stool.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? A. tap water B. hypertonic saline C. mineral oil D. soap and water

hypertonic saline Explanation: The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. 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: A. soft semi-formed. B. bloody. C. liquid consistency. D. mucus-filled.

liquid consistency. Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.

A client with colorectal cancer reports constipation. Which signs or symptoms accompany constipation? A. inability to pass urine B. feeling of abdominal emptiness C. increased bowel movement D. pain on defecation

pain on defecation Explanation: Constipation is accompanied by various signs and symptoms, such as pain on defecation, abdominal distention, and changes in the characteristics of stool, such as oozing liquid stool or hard, small stool. When a person has constipation, he or she does not complain of an increased but a decreased frequency of bowel movements. Clients complain of abdominal fullness or bloating and an inability to pass stool, not urine.

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

past the internal sphincter Explanation: To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

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 Explanation: 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.

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be ordered? A. vitamin D B. vitamin C C. vitamin B12 D. vitamin A

vitamin B12 Explanation: The nurse anticipates that vitamin B12 will be ordered for a client with this type of ostomy, an ileostomy, to prevent vitamin B12 deficiency anemia, since ileostomies are placed before the terminal ileum where vitamin B12 is absorbed. Other answers are incorrect.