Bowel Elimination practice questions
The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? A. Instilling 500 to 1000 mL of lukewarm tap water through the stoma. B. Advising the client to hold the breath if cramping occurs during instillation of the solution C. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso D. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma.
A. Rationale: clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bad is level with the client's shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would clamp the tubing if cramping occurs and then resume the instillation as tolerated. test-taking strategy: focus on the subject, irrigation of a sigmoid colostomy. Visualize this procedure to assist in answering correctly. Eliminate option 3 because of the words "18 inches above." Next eliminate option 4 because the nurse should not "force" tube insertion. To select from the remaining options, eliminate option 2 because of the words "hold the breath." The client should be encouraged to take slow, deep breaths if cramping occurs.
the nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? A. the passage of flatus B. Absent bowel sounds C. The client's ability to tolerate food D. Blooding drainage from the colostomy
A. Rationale: following abdominal perineal resection, the nurse would expect the colostomy to being to function within 72 hours after surgery, although it may take up to 5 days. the nurse would assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would indicate the return of peristalsis. The client would remain NPO (nothing by mouth) until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy. test-taking strategy: focus on the subject, the colostomy beginning to function. This will assist in eliminating option 2. Knowledge of general postoperative measures will assist in eliminating option 3. Focus on the subject to assist in eliminating option 4 as a correct option.
A nurse is preparing to administer a cleansing enema to client. Place the steps the nurse should plan to take in the correct order. A. slowly insert the rectal tube into the client's rectum B. warm the enema solution C. ask the client to retain the solution D. lubricate the end of the rectal tube E. hang the enema container 30 to 45 cm (12 to 18 inches) above the client's anus
B,D,A,E,C when taking actions, the nurse should first warm the enema solution to promote comfort. the next action the nurse should take is to lubricate the end of the rectal tube to promote comfort. The nurse should slowly insert the rectal tube about 7.5 to 10 cm (3 to 4 in) into the client's rectum to reduce the risk of injury of the rectal mucosa. the nurse should hang the enema container 30 to 45 cm (12 to 18 in) above the client's anus to allow for low instillation of the solution. Finally, the nurse should ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to retain it to promote peristalsis and defecation.
A client with gastroenteritis has an as needed prescription for loperamide hydrochloride. For which condition would the nurse administer this medication? A. constipation B. Abdominal pain C. An episode of diarrhea D. Hema test-positive nasogastric tube drainage
C Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4 test-taking strategy: focus on the subject, the action of loperamide. Recalling that this medication is an antidiarrheal agent will direct you to the correct option.
A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? A. prone position B. lithotomy position C. left lateral side-lying position. D. right lateral side-lying position
C. Rationale: for digital removal of stool, the client would be placed in the left later side-lying position, as this position follows the anatomical curvature of the colon. The other choices are all inappropriate. Test-taking strategy: focus on the subject, the correct position for performing digital removal of stool. Remember that for this procedure and most procedures involving manipulation of the rectum and sigmoid colon, the left lateral side lying position is ideal as it follows the normal curvature of the bowel.
A client with Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance
D. Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output so that measures can be implemented to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. test-taking strategy: Note the strategic word, must. Also note the subject, an ileostomy. Remember that ileostomy drainage is liquid, placing the client at risk for fluid and electrolyte imbalance.
A client suspect of having duodenal ulcer has undergone and EDG. The nurse would place highest priority on which item as part of the client's care plan? A Monitoring the temperature B. Monitoring complaints of heartburn C. Giving warm gargles for a sore throat D. Assessing for the return of the gag reflux
D. Rationale: the nurse places highest priority on assessing for return of the gag reflux. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority. test-taking strategy: Note the strategic words, highest priority. Use the ABCs (airway, breathing, circulation. The correct option addresses the airway.
A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? A. Do not eat red meat within one day of the test. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. Ensure the specimen does not include urine
D. When taking actions, the nurse should instruct the client to avoid contaminating the stool specimen with urine or water to ensure accurate test results.
The nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon? A. stoma is beefy red and shiny B. stoma has a purple discoloration C. skin excoriation is noted around the stoma D. semi formed stool is noted in the ostomy pouch.
B. Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi formed stool is a normal finding. Test-Taking strategy: Note the strategic word, immediate and focus on the subject, the observation that requires surgeon notification. Note the words purple discoloration in option 2. Recall that purple indicates ischemia
A nurse is administering a cleansing enema to a client who reports to abdominal cramping. what actions should the nurse take?
when taking actions the nurse should slow the flow of the solution by lowering the container. slowing the flow of the enema should decrease abdominal cramping. If the client is experiencing severe abdominal cramping, stop the enema, assess the client's vital signs, and notify the provider.
A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event B. The client is experiencing early signs of ischemic bowel C. The client should not have the nasogastric tube removed D. This indicates inadequate preoperative bowel preparation
A. Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. B,C,D are all incorrect Test-taking strategy: focus on the subject, that the client is passing flatus from the stoma. Think about the normal functioning of the gastrointestinal tract and note the time frame in the question to assist in answering correctly.
