Ch 35: Bowel elimination

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

Sims Explanation: Sims position is appropriate for a client who will receive this type of enema, as it promotes gravity distribution of the solution. Other choices are incorrect positions.

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. 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.

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." 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.

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

Apply petroleum-based ointment. Explanation: The stoma of an ostomy should be pink and moist. To maintain a healthy stoma the nurse will apply petroleum-based ointment to prevent drying. Alcohol-based products will continue to dry the stoma.

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 Explanation: Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.

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.

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.

A nurse is educating a client on how to irrigate his colostomy. The nurse informs the client that the colostomy should be irrigated in order to:

regulate the timing of bowel movements. Explanation: The purpose of irrigation is to remove formed stool and, in some cases, to regulate the timing of bowel movements. Irrigation does not affect the osmolarity of stool. The drainage of liquid stool and urine is part of continent ostomy. Irrigating a colostomy does not prevent the breakdown of skin, but providing peristomal care to the client does.

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." Explanation: When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause the heart rate to slow and result in syncope in some clients.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent Explanation: Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

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

Ask open-ended questions to elicit why the client is avoiding friends. Explanation: Fecal incontinence is the inability to control bowel movements, causing stool to leak unexpectedly from the rectum. The nurse should not assume that fecal incontinence is the primary reason for the avoidance of friends. While all of the options may be effective in dealing with fecal incontinence, asking open-ended questions to understand why the client is avoiding friends is the best option and most therapeutic

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. Explanation: 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.

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 Explanation: 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.

Then nurse is preparing to apply an external anal pouch. Arrange the following steps in the correct order.

Cleanse entire perianal area and pat dry. Apply skin protectant and allow it to dry. Separate buttocks and apply the pouch to the anal area. Attach the pouch to a collection drainage bag. Hang the drainage bag below the client. Explanation: The correct order when preparing to apply a fecal incontinence pouch is: Cleanse entire perianal area and pat dry. Apply skin protectant and allow it to dry. Separate buttocks and apply the pouch to the anal area. Attach the pouch to a collection drainage bag. Hang the drainage bag below the client.

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. Explanation: The nurse would realize that clients who are constipated should eat more fruits and vegetables. The nurse would realize that clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. The nurse would also realize that clients with food intolerances may experience altered bowel elimination. The nurse would realize that a constipated client would not eat eggs and pasta to relieve the constipation; a better choice would be fruits, vegetables, and increased fiber and fluids if not contraindicated. The nurse would realize that alcohol and coffee do not tend to have a constipating effect on clients.

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

Constipation Explanation: Constipation related to decreased peristalsis is the best nursing diagnosis in this scenario. Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will be absorbed in the colon. Fluid intake issues would be secondary to the primary cause. Diarrhea does not result from peristalsis.

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. Explanation: Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. However, the body breaks down the other components of corn. Chewing corn for longer can also help the digestive system break down cellulose walls to access more of the nutrients. Sucrose, lactose, and galactose are sugars that are not fiber and more easily digestible by the body. During digestion, starches and sugars are broken down both mechanically (e.g. through chewing) and chemically (e.g. by enzymes) into the single units glucose, fructose, and/or galactose, which are absorbed into the blood stream and transported for use as energy throughout the body.

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. Explanation: The nurse would ensure that the client fasted 6 to 12 hours before the test as per policy. The nurse would not provide a light meal before the test, nor administer two Fleet enemas for an EGD. The client would not ingest a gallon of bowel cleanser. The nurse would not give the client a barium contrast mixture to drink.

Which statement about ostomy irrigation is true?

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Explanation: For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance. Daily irrigation is necessary to assure passage of stool from an ileostomy is not warranted as ileostomy do not require daily irrigation. A contract is not necessary to sign to use the equipment. Ostomy prolapse can be delayed by resting until the prolapse recedes and twice daily irrigation is not necessary.

A client reports taking laxatives every day but the client is still constipated. The nurse's response is based on which reasoning?

Habitual laxative use is the most common cause of chronic constipation. Explanation: Occasional use of laxatives is not harmful for most people, but clients should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation.

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

Increase fiber in the diet. Explanation: Opioid use decreases gastrointestinal motility, resulting in constipation. Bowel care strategies include increasing mobility, as well as fiber and fluid in the diet.

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. Explanation: Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.

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

Shower, bathe, or wash peristomal area with mild soapy water. Explanation: After removal of an existing ostomy appliance, the client should be taught to clean the peristomal area or shower or bathe. Other actions take place after cleansing.

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

Insert a lubricated, gloved finger into the rectum. Explanation: The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.

During the physical examination of a client, the nurse percusses the abdomen. In which abdominal quadrant should the nurse expect to hear tympany?

Left upper quadrant Explanation: The nurse would hear tympany in the left upper quadrant (LUQ) upon percussion. Tympany is a high-pitched, hollow sound. The stomach is in the LUQ and contains more air than the small or large intestine. The normal percussion sound heard in the other three quadrants is a hollow sound that is not quite as high-pitched as tympany, reflecting a mixture of air and fluid in the intestines.

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

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 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

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.

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.

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

The stool will be yellow to golden and loose. Explanation: Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and usually have little odor. With formula or cow's milk feedings, infants' stools vary from yellow to brown and are pasty in consistency. As one ages, the stools will become brown and may be firm in texture. Stools should not be green. However, mucus may be present in the stools of infants.

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. 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.

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

Wearing disposable gloves Explanation: The nurse is responsible for obtaining the specimen according to facility procedure, labeling the specimen, and ensuring that the specimen is collected safely and transported to the laboratory in a timely manner. Use of medical aseptic techniques is imperative. Always wear disposable gloves when any contact or handling of a stool specimen is likely. While all actions help prevent contact with the stool, and thus help minimize the risk for injury to the staff, the use of disposable gloves has the greatest impact by being a barrier against direct contamination of the skin by the stool itself.

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

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

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 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.

What is fecal occult blood?

blood that cannot be seen Explanation: Fecal occult blood is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a benzidine-based tests. Hematochezia is bright red blood. Melena is dark red/almost black colored blood. Bloody mucus in stool is not occult.

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." Explanation: In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.

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?" Explanation: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

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

"Ileostomy bag half filled with liquid feces." Explanation: The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid. A colostomy is when a portion of the large intestine is diverted through the abdominal wall.

When caring for a client with fecal incontinence, the client shares feelings of embarrassment. Which statement will the nurse use to respond?

"Neurologic changes that impair muscle activity in your body can cause incontinence." Explanation: Fecal incontinence mainly results from neurologic changes that impair the muscle activity, sensation, or thought processes of a client. It is not a result of the nature of the food consumed by the client or the client's drinking and smoking habits. Fecal incontinence does not necessarily imply that stool is loose or watery, although that may be the case. It is also not the result of the client's social and emotional setting.

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 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." Explanation: With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change.

A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior?

"This is normal when a child this age is hospitalized." Explanation: Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet trained often regress and experience soiling when hospitalized, and scolding or acting disgusted only reinforces the behavior.

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." Explanation: The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for 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." Explanation: The nurse will teach that the FOBT detects heme. It does not test for allergic foods, nor does it test for infection. The fecal immunochemical test (FIT) test results have a high rate of specificity for colorectal cancer.

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) Explanation: The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.

A nurse inserts a rectal suppository into a middle-age female client. The client says that she has an urge to expel the suppository instantly. Which action should the nurse perform?

Ask the client to contract the gluteal muscles. Explanation: The nurse should ask the client to contract the gluteal muscles if there is a premature urge to expel the suppository; it helps to tighten the anal sphincters. Asking the client to remain still in a Sims' position will not control the urge to expel but will facilitate access to the rectum. Asking the client to take deep breaths promotes muscle relaxation; it does not help to control the premature urge to expel the suppository. The nurse avoids placing the suppository within the stool because it reduces the effectiveness of the suppository.

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. 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.

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. 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.

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. 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.

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

Drink at least 2 quarts (1.9 L) of fluids, preferably water, daily. Explanation: During the first 6 to 8 weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells) as well as any other foods that cause diarrhea or excessive flatus. By gradually adding new foods, the ostomy client can progress to a normal diet. The nurse should urge clients to drink at least 2 quarts (1.9 L) of fluids, preferably water, daily. The use of liquid, chewable, or injectable forms rather than long-acting, enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are dangerous because they may cause severe fluid and electrolyte imbalance.

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. Explanation: The client's last bowel movement was one day earlier, so pharmacologic interventions such as suppositories or enemas are not likely warranted at this time. A change in diet may prove helpful, but the nurse's first action should be to provide a setting that is more conducive to having a bowel movement.

"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 scheduling diagnostic studies for a client. Which test would be performed first?

Fecal occult blood test Explanation: Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo multiple studies. They should follow a logical sequence when more than one test is required for accurate diagnosis; that is, fecal occult blood tests to detect gastrointestinal bleeding; barium studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions; and endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide biopsy tissue samples.

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

Monitor for rectal bleeding. Explanation: The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure.

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. Explanation: The nurse would inject 20 to 30 mL of free air into the abdomen in an attempt to reposition the tube and enable flushing of the tube. The situation at hand would not be related to the suction working, so there would be no need to check the suction canister to be sure that it is working appropriately. The nurse would not attempt to flush the tube to ensure its patency. The nurse would have no need to assess the client's abdomen for distention or discomfort.

A nurse needs to administer an oil-retention enema to a client. Which intervention should the nurse perform if disposable equipment is unavailable?

Insert a 14F to 22F tube into the rectum. Explanation: If disposable equipment is not available during an oil retention enema, the nurse should lubricate and insert a 14F to 22F tube into the rectum. A small funnel is not inserted into the rectum but is attached to the tube. The nurse instills approximately 100 to 200 mL of warmed oil slowly only after the tube is inserted in the rectum, not before that. Inserting a suppository in the rectum is not done in an oil retention enema.

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. 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. Attapulgite interferes with the absorption of other oral medications. Loperamide is not an antimicrobial agent.

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. Explanation:If the client experiences severe cramping when the enema solution is introduced, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. A client should not be placed on a bedpan until after the rectal tube is removed. The rectal tube does not need to re-positioned or removed.

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

Nothing; this is a good diet. Explanation: A high-fiber diet and a daily fluid intake of ten to twelve 8-oz glasses (2,500 to 3,000 mL) of fluids facilitate bowel elimination. Intake of the foods described makes the feces bulkier, so they move through the intestine more quickly. The stool is softer and the time to absorb toxins (believed to have a role in the development of colon cancer) is decreased.

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

Rotate the catheter tip inside the stoma. Explanation: When the catheter becomes plugged with stool or mucus, the nurse should try to rotate the catheter tip inside the stoma to clear the obstruction. The nurse could also try to milk the catheter in order to clear it. However, the nurse or client should not wait longer than 6 hours without obtaining drainage as it could lead to further complications. If all the above actions fail, the nurse should simply remove the catheter, rinse it, and try again.

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

Sims Explanation: Sims position is appropriate as it promotes gravity distribution of the solution. Other choices are incorrect positions.

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 Explanation: The incidence of constipation tends to be high among clients whose dietary habits lack sufficient raw fruits and vegetables, whole grains, seeds, and nuts, all of which contain adequate fiber. Dietary fiber, which becomes undigested cellulose, is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. A diet lacking in glucose and water will cause dehydration first and then constipation, depending on other constituents of the diet. Diets consisting of whole (not refined) grains, seeds, and nuts provide fiber, which helps in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.

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. 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.

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 Explanation: Some clients experience cramping when receiving a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion. A slower infusion rate may be necessary. Other choices are incorrect.

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

brown rice Explanation: The nurse will recommend brown rice, a food that is high in dietary fiber. Other selections listed do not contain high fiber.

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.

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 Explanation: There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

A nurse is caring for a client with a colostomy. What type of stools would the nurse 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.

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 Explanation: 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.

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 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.

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

increased bowel sounds Explanation: The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds. Abdominal tenderness, distension, and muscular resistance, wouldn't be expected following a small volume enema.

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 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 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 an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds Explanation:Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. Other assessment findings are normal.

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

sulfamethoxazole-trimethoprim Explanation: Antibiotics, such as sulfamethoxazole-trimethoprim, can cause diarrhea. Morphine, iron supplement, and immobility are likely causes of 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 Explanation: The nurse will ask about new medications, because these can often cause constipation; what the client's normal bowel habits are like to establish a baseline; and whether the client has used laxatives to pass stool in the pass. A sensation of rectal fullness is associated with constipation. Loose stool is associated with diarrhea.

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

Measure from the tip of earlobe to tip of nose to the tip of xiphoid process. Explanation: To determine the length of the nasogastric tube to be inserted, the nurse would measure from the tip of the earlobe to the tip of the nose to the tip of the xiphoid process.

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. Explanation: Signs that the client is constipated include abdominal distension due to bloating and fullness. The intestinal tract is full of stool; however, the client is unable to move the fecal content leading to actual fullness and distension. Fullness in the rectum is characteristic of constipation because, as there is stool sitting idle in the intestinal tract with constipation, the fecal matter is also in the rectum creating fullness and discomfort at the sphincter. Some clients may even report rectal pain if the constipation is moderate to severe. Cramping and bowel urgency are characteristic signs of diarrhea and typically do not accompany constipation. Because many clients are accustomed to having at least one bowel movement per day, they may believe that they are constipated simply because they are not having a bowel movement as often. This does not constitute constipation and, therefore, requires less invasive interventions such as changes to levels of activity and fluid and fiber intake. Pseudoconstipation, also referred to as perceived constipation, is a term used when clients believe themselves to be constipated, even though they are not.

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

The stoma is protruding into the bag and may become twisted. Explanation: During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma which will require a surgical intervention. The peristomal skin is excoriated or irritated because the appliance is cut too large is not associated with a prolapse stoma. The system has leaks or poor adhesion leading to noticeable odor is related to poor adhesion and not related to the prolapse stoma. The bag continues to come loose and become inverted is related to the bag appliance and not the stoma.

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. Explanation: 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.

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.

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 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 nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?

lubricates and softens stool Explanation: Cottonseed, olive oil, or mineral oil lubricates and softens the stool so that it can be expelled more easily during a retention enema. Tap water and normal saline solution distend the rectum and moisten the stool, whereas a soap and water solution not only distends the rectum and moistens the stool but also irritates the local tissue. A hypertonic saline solution irritates local tissue.