Chapter 38: Bowel Elimination

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

Sims

The nurse is 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

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 two days ago.

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."

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

- Watch for liquid bowel movements after days with none. - You may experience pain on defecation.

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds."

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse?

"Children vary in their readiness but daytime bowel control may be attained at 30 months."

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 prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. "When you inspect the stoma, it should be dark purple-blue." "The size of the stoma will stabilize within 2 weeks." "Keep the skin around the stoma site clean and moist." "The stool from an ileostomy is normally liquid." "You should eat dark-green vegetables to control the odor of the stool." "You may have a tendency to develop food blockages."

"The stool from an ileostomy is normally liquid." "You should eat dark-green vegetables to control the odor of the stool." "You may have a tendency to develop food blockages."

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?"

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"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."

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?

3 in (7.5 cm)

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

50-year-old client with a family history of polyps

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. A patient diagnosed with peritonitis A patient who is on prolonged bedrest A patient who has diarrhea A patient who has gastroenteritis A patient who has an early bowel obstruction A patient who has paralytic ileus caused by surgery

A patient diagnosed with peritonitis A patient who is on prolonged bedrest A patient who has paralytic ileus caused by surgery

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. A patient who is taking narcotics for pain A patient who is taking metformin for type 2 diabetes mellitus A patient who is taking diuretics A patient who is dehydrated A patient who is taking amoxicillin for an infection A patient taking over-the-counter antacids

A patient who is taking metformin for type 2 diabetes mellitus A patient who is taking amoxicillin for an infection A patient taking over-the-counter antacids

For which patient would a nurse expect the primary care provider to order colostomy irrigation? A patient with IBS A patient with a left-sided end colostomy in the sigmoid colon A patient with post-radiation damage to the bowel A patient with Crohn's disease

A patient with a left-sided end colostomy in the sigmoid colon

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 nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? A saline osmotic laxative A bulk-forming laxative Methylcellulose A stool softener

A saline osmotic laxative

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.

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

Affects absorption of fat-soluble vitamins

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

Apply skin barrier to the tip and end of the nose.

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client?

Assess the color of the stoma.

A 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.

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

Auscultate for bowel sounds.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

Auscultation

A 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

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

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.

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

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

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

Bright yellow

A nurse is irrigating a client's nasogastric tube. Place the following steps in the correct order. Use all options.

Check placement of the nasogastric tube. Draw up 30 mL of irrigation solution into a syringe. Clamp the nasogastric tube near the connection site. Hold the syringe upright, and gently insert the irrigant. Hold the end of the nasogastric tube over an emesis basin. Inject air into the blue air vent.

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

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

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

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

Which symptom is a known side effect of antibiotics?

Diarrhea

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.

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.

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

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

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. Draw up 30 mL of saline solution into the syringe. Unclamp the suction tubing near the connection site to instill solution. Place the tip of the syringe in the tube to gently insert saline solution. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. After instilling irrigant, hold the end of the NG tube over an irrigation tray. Observe for return flow of NG drainage into an available container.

Draw up 30 mL of saline solution into the syringe. Place the tip of the syringe in the tube to gently insert saline solution. After instilling irrigant, hold the end of the NG tube over an irrigation tray. Observe for return flow of NG drainage into an available container.

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

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

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

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.

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

Grapefruit

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? Have the patient follow a low-fiber diet several days before the test. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. Prepare the patient for the use of general anesthesia during the test. Explain that barium contrast mixture will be given to drink before the test.

Have the patient follow a low-fiber diet several days before the test.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? Reassure the patient that this is a normal finding with a new ostomy. Notify the primary care provider that the stoma is prolapsed. Have the patient rest for 30 minutes to see if the prolapse resolves. Remove the appliance and redo the procedure using a larger appliance.

Have the patient rest for 30 minutes to see if the prolapse resolves.

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 caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? Incontinence Constipation Electrolyte imbalances Infection

Incontinence

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

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

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

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

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

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

Liquid consistency

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 administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? Elevate the head of the bed 30 degrees and reposition the rectal tube. Place the patient in a supine position and modify the amount of solution. Lower the solution container and check the temperature and flow rate. Remove the rectal tube and notify the primary care provider.

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

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?

Measure the tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process.

A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? Using a diet that is low in bulk Decreasing fluid intake to 1,000 mL Administering an enema once a day to stimulate peristalsis Monitoring bowel movements

Monitoring bowel movements

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 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

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

Palpation

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

Plans to eat a snack of fruit twice per day.

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

Secondary constipation

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily.

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse's next action? Reassure the patient that this is a normal reaction to the procedure. Stop the procedure, prepare to administer CPR, and notify the primary care provider. Stop the procedure, assess vital signs, and notify the primary care provider. Stop the procedure, wait 5 minutes, and then resume the procedure.

Stop the procedure, assess vital signs, and notify the primary care provider.

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

The NG tube is in the client's airway

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

The client takes bisacodyl every day.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? The nurse administers a large volume of solution (500 to 1,000 mL) The nurse mixes milk and molasses in equal parts for an enema The nurse instructs the patient to retain the enema for at least 30 minutes The nurse administers the enema while the patient is sitting on the toilet

The nurse instructs the patient to retain the enema for at least 30 minutes

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

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

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

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.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk

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.

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

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 proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea.

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

antibiotics, acute stress, depression

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? c, b, d, a d, c, a, b a, b, d, c b, a, d, c

b, a, d, c

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

cecum

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

lentils cabbage onions