Chapter 38: Bowel Elimination

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply. "Where do you do your grocery shopping?" "How often do you go out to eat?" "How often do you move your bowels?" "Do you prefer hot foods or cold foods?" "Do you use anything to help move your bowels?"

- "Do you use anything to help move your bowels?" - "How often do you move your bowels?" Explanation: To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1421.

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. a positive family history a history of inflammatory bowel disease age 50 and older a diet high in fruits, vegetables, and whole grains.

- age 50 and older - a positive family history - a history of inflammatory bowel disease Explanation: The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1428.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply. yellow clay colored dark brown light brown black

- 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1427.

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?" "Is the stool difficult to pass?" "Are you experiencing rectal fullness?" "Do you use laxatives?"

-"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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1421-1425.

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 expresses interest in learning self-care." "The client agrees to take prescribed antidepressants." "The client uses spray deodorant several times an hour to mask odor." "The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy."

-"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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1447.

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. Planning medical treatment based on test results Collecting the specimen Transporting the specimen Handling the specimen Ordering the test Teaching the client about the test

-Collecting the specimen -Handling the specimen -Transporting the specimen -Teaching the client about the test Explanation: The nurse should follow facility protocol to collect, handle, and transport a specimen. It is very important to adhere to protocols and standards, collect the appropriate amount, use appropriate containers and media, and store and transfer the specimen within specified timelines. Client teaching is also an important part of specimen collection. The primary health care provider orders the test and plans medical treatment based on the results. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1428-1429.

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

-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 flatulence Explanation: Rapid ingestion of food, improper use of straws, smoking, and excessive carbonated beverages may all be causes of flatulence. Caffeinated beverages typically do not cause flatulence. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1437-1438.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. dark brown light brown black clay colored yellow

-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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1427.

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 ice cream with lunch and dinner prune juice with breakfast diet soda with lemon hot tea with meals

-hot tea with meals -a turkey sandwich with whole-grain bread -prune juice with breakfast Explanation: A glass of prune juice is equivalent to more than one serving of the dried fruit, has high magnesium content, and is an excellent source of fluid to promote bowel elimination. Hot fluids, such as coffee, tea, or hot water with lemon juice, may also increase intestinal motility. High fiber foods such as whole-grain bread provide bulk for the stool. Ice cream and diet soda do not provide any preventative measures for constipation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1421.

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply. onions lentils cabbage shrimp pork chops chicken nuggets

-lentils -onions -cabbage Explanation: Lentils, onions, and cabbage are known to produce gas. Meats are generally not associated with formation of gas. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1437.

A parent brings a 2-year-old child 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." Which response by the nurse is appropriate? A.) "Children vary in their readiness but daytime bowel control may be attained at 30 months." B.) "There may be something wrong since your child should be toilet trained by 2 years of age." C.) "You are putting too much pressure on yourself and your child to toilet train." D.) "There is nothing to worry about. Just keep the child in diapers until they stop having accidents."

A.) "Children vary in their readiness but daytime bowel control may be attained at 30 months." Explanation: Successful bowel training also includes awareness by the child of the need to defecate, the ability of the child to communicate this need, the child's wish to please the parent involved in bowel training, and the parent's praise and reinforcement for the child's successful behavior. Daytime bowel control is normally attained by 30 months of age, but the age varies with each child. Informing the parent that pressure is too much for the child may make the parent feel guilty and should be avoided. The nurse should never tell the parent that something is wrong if the child is not toilet trained, because this may vary with all children. The nurse is being dismissive when telling the parent that there is nothing to worry about. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1421.

The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education? A.) "I will have a fecal occult blood test done every 5 years." B.) "My mother had colon cancer so I am at a greater risk for also developing colon cancer." C.) "I will have a flexible endoscopic exam done every 5 years." D.) "I will need yearly screenings for colon cancer."

A.) "I will have a fecal occult blood test done every 5 years." Explanation: Yearly screenings, including a fecal occult blood test, should be done on all clients over the age of 50. A flexible endoscopic exam should be done every 5 years. A family history of colorectal cancer increases the risk of developing colorectal cancer. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1429.

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? A.) "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." B.) "There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement." C.) "This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart." D.) "This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid."

A.) "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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1420.

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? A.) 3 in (7.5 cm) B.) 1 in (2.5 cm) C.) 2 in (5.0 cm) D.) 5 in (12.5 cm)

A.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1419.

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? A.) Attempt to irrigate the NG tube with water or normal saline. B.) Remove the NG tube and replace it with a larger-bore tube, as ordered. C.) Instill digestive enzymes, as ordered. D.) Turn off the suction for 30 minutes and then turn it on again.

A.) Attempt to irrigate the NG tube with water or normal saline. Explanation: An NG tube that is not draining should normally be irrigated. Turning the suction off and on is less likely to be effective, and it may be unsafe to leave the suction turned off for half an hour. Digestive enzymes are not used on NG tubes that are used for suction. Removing the NG tube would be an action of last resort. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1465-1467.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? A.) Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. B.) Administer an oral analgesia 30 to 45 minutes before attempting insertion. C.) Position the bed flat and assist the client onto his or her left side. D.) Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point.

A.) Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. Explanation: To insert a nasointestinal tube, the nurse should measure the tube from the tip of nose to the earlobe and from the earlobe to the xiphoid process and add 8 to 10 in (20 to 25 cm) for intestinal placement. The client should be placed on his or her right side. Analgesia is not normally required in anticipation of placement. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1457-1462.

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.) Remove the tubing. C.) Discontinue the administration of the enema D.) Continue infusing at a faster rate to finish the enema quicker.

A.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1455.

Which symptom is a known side effect of antibiotics? A.) Diarrhea B.) Abdominal bloating C.) Constipation D.) Fecal impaction

A.) Diarrhea Explanation: A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1437.

The nurse is preparing to administer an enema to a client who is constipated. Upon assessment, the nurse notes painful distended veins on the exterior rectum. Which action will the nurse take next? A.) Generously lubricate the enema tube tip before proceeding. B.) Use a different solution for the enema. C.) Digitally stimulate the client to defecate. D.) Continue with the enema with no further intervention.

A.) Generously lubricate the enema tube tip before proceeding. Explanation: Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. Hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Hemorrhoids can tear due to the firm enema tip; therefore, the enema tip should be generously lubricated and administered with caution to avoid tearing. Continuing as usual is inappropriate due to the hemorrhoid finding. Nurses do not digitally stimulate a client to void. The decision to change the enema solution is a health care provider order; therefore, the nurse cannot perform this option without speaking with the provider first. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1419.

Which principle should guide the nurse's collection of a fecal occult blood test? A.) If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. B.) The results of the test will preliminarily indicate the site of a client's bleeding. C.) The nurse must assess the client's food and medication intake for the 2 weeks prior to the test. D.) Recent use of over-the-counter stool softeners can cause a false-positive result.

A.) If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. Explanation: In a woman who is menstruating, the test should be postponed until 3 days after her period has ended. Before stool testing, the client should avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results; there is no need to assess for a 2-week window. Stool softeners do not confound the results of testing. Results indicate the presence of blood, but not its source. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1428-1429.

Which medication causes constipation? A.) Iron supplements B.) Bisacodyl C.) Magnesium antacids D.) Aspirin

A.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1422.

A nurse attempts to administer a tap water enema to a client who is dehydrated and finds that the client cannot retain the enema for the prescribed amount of time. What nursing action would be appropriate for this client? A.) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. B.) Place the client in a sitting position on the toilet and lower the enema solution. C.) Stop the enema and reposition the rectal tube or remove it to check for any fecal contents. D.) Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the health care provider.

A.) Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. Explanation: If the client cannot retain the enema solution for an adequate amount of time, place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort. If still unable to retain the solution, notify the health care provider. The nurse does not need to reposition the rectal tube but needs to assist the client by repeating the procedure with a slight variation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1439-1440.

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.) Asparagus and turnip C.) Fish and dried lentils D.) Onions and garlic

A.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1449.

The proliferation of Clostridium difficile causes: A.) antibiotic-associated diarrhea. B.) Urinary Clostridium infection. C.) Escherichia coli diarrhea. D.) anal yeast infection.

A.) antibiotic-associated diarrhea. Explanation: Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1424-.

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

A.) physiologic or lifestyle changes in the client. Explanation: Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1421.

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.) "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." D.) "That's correct, but be sure that you don't increase your laxative doses over time."

B.) "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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1420.

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? A.) "Flatus is a natural action and the cause is unknown." B.) "Certain vegetables can cause flatus, as they are more difficult to digest." C.) "Parasites in your stool can cause persistent flatus." D.) "Drinking alcoholic beverages can cause flatus."

B.) "Certain vegetables can cause flatus, as they are more difficult to digest." Explanation: Flatus is gas in or from the stomach or intestines that is passed through the anus. Foods that contain high amounts of fiber, such as vegetables, commonly produce flatus due to being harder to digest. Flatus is not likely related to a parasitic infection or drinking alcoholic beverages. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Long-term Ostomy Care, p. 1449.

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? A.) "As long as you wash the area and dry carefully, you can use the test." B.) "Wait to do the test 3 days after your finish menstruating." C.) "Menstruation will not alter the test results. Go ahead with the test." D.) "If you are having a light flow or spotting then you can perform the test."

B.) "Wait to do the test 3 days after your finish menstruating." Explanation: The client should be sure to postpone the test until 3 days after cessation of menstruation. If not, the client may experience a false-positive test. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1429.

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? A.) 2 in (5.0 cm) B.) 3 in (7.5 cm) C.) 1 in (2.5 cm) D.) 5 in (12.5 cm)

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1419.

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? A.) If unable to irrigate the tube, remove it and obtain an order for replacement. B.) Assist the client to a 30- to 45-degree position, unless this is contraindicated. C.) Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. D.) If Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent.

B.) Assist the client to a 30- to 45-degree position, unless this is contraindicated. Explanation: To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe. If a Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1465-1467.

A paraplegic man receives care in the rehabilitation facility. He confides in a nurse that he has trouble controlling his bowel movements. He tends to normally stool 6 to 8 times per day. This has caused the skin around his rectum to become irritated. Which is not an appropriate NANDA-I diagnosis for this client? A.) Risk for Disturbed Body Image r/t fecal incontinence B.) Diarrhea r/t decreased muscle tone and sphincter control C.) Risk for Impaired Skin Integrity r/t fecal incontinence D.) Fecal Incontinence r/t decreased muscle tone and sphincter control

B.) Diarrhea r/t decreased muscle tone and sphincter control Explanation: This client is not currently experiencing diarrhea. He does not describe his stools as watery or loose. Rather, this client's problem is with control of the bowel. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1433.

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? A.) Obtain a diet change order to increase the amount of fiber in the client's meals. B.) Facilitate a more private setting, such as assisting the client to a bathroom. C.) Administer a normal saline enema after obtaining the relevant order. D.) Position the client on his side and administer a glycerin suppository.

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1441.

Which statement about ostomy irrigation is true? A.) Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. B.) For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. C.) Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery. D.) Daily irrigation is necessary to assure passage of stool from an ileostomy.

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1448.

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? A.) Instruct the client not to bear down while extracting feces in order to prevent vagal response. B.) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. C.) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. D.) Position the client supine, as dictated by client comfort and condition.

B.) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Explanation: For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1442.

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.) If diarrhea is still present after 48 hours, continue giving diphenoxylate and atropine. B.) Keep the client's bed in the lowest position. C.) Check with health care provider before giving diphenoxylate and atropine to a child. D.) Encourage the client to eat fresh fruits and vegetables.

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1470.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? A.) Right lateral B.) Left lateral C.) Prone D.) Semi-Fowler's

B.) Left lateral Explanation: The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1430.

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? A.) Carminative B.) Oil-retention C.) Anthelmintic D.) Hypertonic

B.) Oil-retention Explanation: Oil-retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. A hypertonic enema draws water into the colon, which stimulates the defecation reflex. Carminative enemas help to expel flatus from the rectum and relieve distention secondary to flatus. Anthelmintic enemas are administered to destroy intestinal parasites. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Table 38-4, p. 1439.

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

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1428.

The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema? A.) Serum albumin of 3.1 g/dL (31 g/L) B.) Platelet count of 18,000/mm3 C.) White blood cell (WBC) count of 15,200/mm3 (15.20 × 109/L) D.) Arterial pH of 5.2

B.) Platelet count of 18,000/mm3 Explanation: A platelet count of less than 20,000/mm3 (20.00 × 109/L) may seriously compromise the client's ability to clot blood. Therefore, the nurse should not perform any unnecessary procedures that would place the client at risk for bleeding or infection, such as giving an enema. A serum albumin level of 3.1 g/dL (31 g/L) suggests malnutrition. An arterial pH level of 5.2 indicates acidosis. A WBC count of 15,200/mm3 (15.20 × 109/L) suggests infection. Malnutrition, acidosis, and infection would not contraindicate administering an enema. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1453-1457.

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

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed? A.) Empties the pouch before changing the appliance B.) Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate C.) Applies a skin protectant to a 2-in (5-cm) radius around the stoma and allows it to dry completely D.) Places a disposable pad on the work surface

B.) Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate Explanation: When removing the appliance, the nurse should start at the top, not bottom, to prevent spillage of intestinal content. The disposal pad protects the work surface. Emptying the appliance before removal prevents spillage of fecal material. The skin should dry completely to provide good adherence of the appliance; applying a protectant to a 2-in (5-cm) radius around the stoma provides protection to the skin and prevents breakdown. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1448.

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, withdraw the tubing slightly, then resume the enema. B.) Stop the procedure, monitor heart rate and blood pressure. C.) Stop the procedure and reposition the client. D.) Slow the infusion rate, have the client take deep breaths, then resume the enema.

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

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? A.) The client is forcefully resisting the procedure. B.) The NG tube is in the client's airway. C.) The NG tube is curled in the back of the client's throat. D.) The client is experiencing a vasovagal reaction.

B.) The NG tube is in the client's airway. Explanation: The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1457-1462

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? A.) The student placed the client in supine position with the abdomen exposed. B.) The student sequenced from auscultation to inspection, and percussion to palpation. C.) The student had the client flex the knees when performing the assessment. D.) The student instructed the client to urinate before beginning the focused assessment.

B.) The student sequenced from auscultation to inspection, and percussion to palpation. Explanation: The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1426.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet? A.) a diet lacking in refined grains, seeds, and nuts B.) a diet lacking in fruits and vegetables C.) a diet lacking in meat and poultry products D.) a diet lacking in glucose and water

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1423.

The nurse is managing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? A.) irrigating a client's nasogastric tube B.) emptying a client's ileostomy appliance C.) assessing a client's gastrointestinal system D.) inserting a client's nasogastric tube

B.) emptying a client's ileostomy appliance Explanation: It is safe for an experienced unlicensed assistive personnel (UAP) to empty an ostomy. Gastrointestinal assessment and insertion and irrigation of a nasogastric tube cannot be delegated because they are under the scope of practice of the registered nurse. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1468-1473.

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? A.) barium studies, endoscopic examination, fecal occult blood test B.) fecal occult blood test, barium studies, endoscopic examination C.) barium studies, fecal occult blood test, endoscopic examination D.) endoscopic examination, barium studies, fecal occult blood test

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1432.

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.) soap and water D.) mineral oil

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1439-1440.

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.) mucus-filled. B.) liquid consistency. C.) bloody. D.) soft semi-formed.

B.) liquid consistency. Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1445

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding? A.) iatrogenic constipation B.) secondary constipation C.) primary constipation D.) pseudoconstipation

B.) secondary constipation Explanation: The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1434.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? A.) ileostomy B.) sigmoid colostomy C.) transverse colostomy D.) ascending colostomy

B.) sigmoid colostomy Explanation: Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as the site of the colostomy in the colon (preferably the sigmoid colostomy where constipation occurs) and the client's and health care provider's preferences, determine whether a colostomy is to be irrigated. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled. The transverse and ascending colon are located before the sigmoid area, which is closest to the rectum. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1446.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? A.) heart rate 90 beats/min B.) skin turgor response 5 seconds C.) temperature 99.9°F (37.9°C) D.) blood pressure 130/80 mm Hg

B.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1436.

The nurse is conducting teaching with a client who has a prescription for a wireless capsule endoscopy. Which statement by the client would indicate to the nurse that the teaching was effective? A.) "I will return 24 to 48 hours after swallowing the capsule to have the capsule removed." B.) "I will feel bloated and uncomfortable because of the air used to expand my small intestine." C.) "I can go about my daily routine while the camera is passing though my small intestine." D.) "I will not be allowed to eat anything after the first 4 hours of the study."

C.) "I can go about my daily routine while the camera is passing though my small intestine." Explanation: While the camera is passing through the small intestine, the client may resume normal activities. The client can have a small meal after the first 2 hours of the study. No air is used to expand the small intestine, so the client should not feel bloated and uncomfortable. The capsule will be excreted 24 to 48 hours after ingestion via normal defecation process. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1431.

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."

C.) "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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1435.

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? A.) "Stool cannot be collect from a child's diaper." B.) "Stool can be collected only from a cloth diaper." C.) "Only if the stool has not been contaminated by urine." D.) "It depends on which testing developer is used."

C.) "Only if the stool has not been contaminated by urine." Explanation: Stool can be collected from a diaper for occult blood testing only if the stool has not been contaminated by urine. It does not matter whether the diaper is disposable or cloth. The type of developer does not make a difference as all are used to test for occult blood. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1428-1429.

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? A.) "This test will determine whether foods are contributing to rectal bleeding." B.) "This test will show if you have an infection in the bowel." C.) "This test detects heme, a type of iron compound in blood in the stool." D.) "This test will show if you have colorectal cancer."

C.) "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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1429.

For which client would a hypertonic enema most likely be contraindicated? A.) A client who is severely constipated B.) A client who has peripheral edema C.) A client with renal impairment D.) A client with type 1 diabetes

C.) A client with renal impairment Explanation: Hypertonic solutions are contraindicated for clients with renal impairment or reduced renal clearance, because these clients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia. Diabetes, constipation, and edema do not necessarily contraindicate the safe and effective use of a hypertonic enema. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

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

C.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1429.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? A.) If the specimen contains barium or enema solution, document this on the container. B.) Refrigerate the specimen until it is cooled before sending it to the laboratory. C.) Collect 15 to 30 mL of the client's liquid stool. D.) If portions of the stool include visible blood, mucus, or pus, discard the stool.

C.) Collect 15 to 30 mL of the client's liquid stool. Explanation: Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1428-1429.

A nurse is administering a client's large-volume enema. What assessment finding would indicate to the nurse that the solution is being administered too quickly? A.) Urge to defecate B.) Diaphoresis (sweating) and facial flushing C.) Decrease in heart rate D.) Rectal bleeding

C.) Decrease in heart rate Explanation: Rapid administration of a large-volume enema can precipitate a vagal response, resulting in decreased heart rate. Diaphoresis and an urge to defecate may occur, but these are not likely the result of infusing the solution too quickly. Bleeding must be promptly addressed as it signals trauma to the intestinal mucosa. However, this is likely the result of insertion of the rectal tube, not rapid infusion of solution. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1454.

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

C.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1426.

The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? A.) Bacon B.) Eggs C.) Grapefruit D.) Whole milk

C.) Grapefruit Explanation: Constipation may be avoided, minimized, or eliminated with proper food selection. Citrus fruits, such as grapefruit, are good choices for a client with constipation as they are rich in soluble fiber pectin, which increases gastrointestinal motility. Bacon contains high fat, which increases constipation. Eggs are low in fiber and high in fat, which slows gastrointestinal motility. Fat in whole milk is constipating. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Food and Fluid, p. 1422.

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? A.) Will include fish one to two times per week. B.) Will includes a pat of butter with eggs for breakfast. C.) Plans to eat a snack of fruit twice per day. D.) Plans to eat 4 ounces of protein 3 times per day.

C.) Plans to eat a snack of fruit twice per day. Explanation:By snacking on fruits and vegetables, the client can increase fiber in the diet. The amount of fish, protein, and fat do not relate to increasing or absorbing fiber in the diet. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1422-1423.

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

C.) Reinstruct the client on use of collection container for next bowel movement. Explanation: Stool should not be collected from the toilet due to contamination. The nurse should reinstruct the client on the use of a collection container for the next bowel movement. There is nothing to indicate that the test should be cancelled nor that the client needs a laxative administered. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1428.

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor? A.) The client eats five to six small meals per day. B.) The client drinks 8 glasses of fluid daily. C.) The client takes bisacodyl every day. D.) The client traveled to South America two weeks ago.

C.) The client takes bisacodyl every day. Explanation: Habitual use of laxatives such as bisacodyl may cause of chronic constipation. Traveling to South America usually causes a client to develop traveler's diarrhea. Drinking eight glasses of fluid daily promotes bowel elimination. Consuming five to six small meals per day should not contribute to constipation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1435.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk? A.) Taking sample directly from commode insert B.) Not removing commode insert from commode C.) Wearing disposable gloves D.) Using a tongue depressor to access stool

C.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Stool Collection, p. 1428.

For which client would digital removal of stool be contraindicated? A.) a client with a urinary tract infection B.) a client with a spinal cord injury C.) a client recovering from prostate surgery D.) a diabetic client with renal complications

C.) a client recovering from prostate surgery Explanation: Digital removal of stool should not be performed on clients who have bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. None of the other listed health problems contraindicate digital removal of stool. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1441.

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema? A.) promotes bowel movement without irritation effect B.) lubricates and softens the stool C.) draws fluid from body tissues into the bowel D.) causes chemical irritation of the mucous membranes

C.) draws fluid from body tissues into the bowel Explanation: A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation? A.) hypertonic saline solution B.) tap water and soap solution C.) tap water and normal saline solution D.) cottonseed or olive oil solution

C.) tap water and normal saline solution Explanation: Tap water and normal saline solution is preferred for cleansing the bowel in preparation for a rectal examination because of its non-irritating effects. A combination of tap water and soap solution is not suitable because soap causes chemical irritation of the mucous membranes. A concentrated hypertonic saline solution also acts as a local irritant on the mucous membranes. Cottonseed or olive oil solution is also not suitable because the oil solution is held within the large intestine, and if the client has premature defecation, it could defeat the purpose of retention. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

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? A.) Nasogastric tubes should not be irrigated. B.) Every 8 to 10 hours C.) Every 1 to 2 hours D.) Every 4 to 8 hours

D. Every 4 to 8 hours Explanation: The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1465-1468.

The nurse is caring for a client who has orders to receive a hypertonic enema. The client asks what is going to happen during the procedure. Which response by the nurse is appropriate? A.) "Do not try to hold the enema in; it will cause pain." B.) "Lay flat on your back with your knees pulled to your chest." C.) "You will need to lay completely on your stomach." D.) "I will keep you covered as much as possible during the procedure."

D.) "I will keep you covered as much as possible during the procedure." Explanation: Administration of medications using the rectal route can be embarrassing for the client; it is essential to provide for client privacy. The proper client positioning is the Sims position, not supine or prone. Enema solution should be retained as long as possible to help with the evacuation effect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1454.

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

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1422.

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.) The appliance will fit securely to the client's skin. B.) The appliance will need to be changed daily. C.) A heightened risk that the stoma will prolapse D.) A risk that the peristomal skin will become excoriated

D.) A risk that the peristomal skin will become excoriated Explanation: An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1468-1473.

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? A.) Apply device for stool collection. B.) Perform stoma irrigation. C.) Have the client perform self stoma care D.) Assess the color of the stoma.

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1446.

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? A.) Measure abdominal girth. B.) Ask when the client last had a bowel movement. C.) Observe the abdominal dressing. D.) Auscultate for bowel sounds.

D.) Auscultate for bowel sounds. Explanation: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention. Abdominal surgery places the client at risk for developing a paralytic ileus. The nurse would auscultate for bowel sounds, as absent bowel sounds 72 hours after abdominal surgery may signal that the client has developed a paralytic ileus. Measuring abdominal girth, asking about past bowel movements, and observing the dressing would not provide the needed information to determine if a paralytic ileus is occurring. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Auscultation, p. 1426.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? A.) Attach a syringe and flush with 50 mL of water or normal saline before removal. B.) Place the client in a protective supine position to facilitate easy removal. C.) Quickly and carefully remove tube while the client breathes out. D.) Before removing the tube, discontinue suction and separate the tube from suction.

D.) Before removing the tube, discontinue suction and separate the tube from suction. Explanation: When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1463-1465.

The nurse is doing preoperative teaching with a client who has a prescription for Golytely® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner? A.) Warm B.) Room temperature C.) In fruit juice D.) Chilled

D.) Chilled Explanation: GoLYTELY® has a salty taste and is better tolerated if consumed cold. It is a powder that is mixed with water, not fruit juice. Drinking it at room temperature or warm does not enhance its taste. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1440-1441.

The nurse is caring for four clients with diarrhea. When reviewing the client's chart, the nurse would contact the health care provider if which client has a prescription for an antidiarrheal agent? A.) Client with a bowel tumor B.) Client with alcohol use C.) Client with Crohn's disease D.) Client with food poisoning

D.) Client with food poisoning Explanation: Clients with acute diarrhea (food poisoning) should not receive an antidiarrheal until a bacterial causative agent is ruled out. Clients with chronic diarrhea (Crohn's disease, bowel tumor, and alcohol use) may require pharmacologic intervention. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1437.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response? A.) Corn is high in lactose, which is an insoluble fiber that the body cannot digest. B.) Corn is high in galactose, which is an insoluble fiber that the body cannot digest. C.) Corn is high in sucrose, which is an insoluble fiber that the body cannot digest. D.) Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Box 38-3, p. 1449.

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? A.) Provide a light meal before the test and administer two Fleet enemas. B.) Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. C.) Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. D.) Ensure that the client fasts 6 to 12 hours before the test as per policy.

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1429.

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? A.) Drink a soft drink daily to prevent gas and allow fiber to break down. B.) Eat more cabbage and Brussel sprouts to decrease gas and add fiber. C.) Include more protein in the diet to increase fiber and decrease gas. D.) Increase fiber slowly over a period of time to prevent gas.

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, Food and Fluid, p. 1422.

A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation? A.) Place the client on a bedpan in the supine position while receiving the enema. B.) Reposition the rectal tube and check for any fecal content. C.) Remove the tubing immediately and discontinue the procedure. D.) Lower the solution container and check the temperature and flow rate.

D.) Lower the solution container and check the temperature and flow rate. Explanation: If the client complains of 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. This assessment should precede removal of the tube or repositioning the client or the tube. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, pp. 1453-1456.

The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. The nurse would intervene if which food item is included on the client's tray? A.) Scrambled eggs B.) Steamed haddock C.) Cream of wheat D.) Sliced red apples

D.) Sliced red apples Explanation: Fresh fruits are high in fiber and should be avoided in a low-fiber diet. Refined grains (cream of wheat), eggs, and fish (steamed haddock) are low in fiber. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1430.

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

D.) Stop the administration of the enema momentarily. Explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the health care provider. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1455.

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

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1471.

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.) percussion. B.) light palpation. C.) deep palpation. D.) auscultation.

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1426.

A student nurse studying human anatomy knows that a structure of the large intestine is the: A.) duodenum B.) jejunum C.) ileum D.) cecum

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1419.

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.) retention enema B.) return-flow enema C.) carminative enema D.) cleansing enema

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

An older adult woman who is incontinent of stool following a cerebrovascular accident. Which nursing concern will the nurse identify for planning care? A.) diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency B.) retention of fecal matter related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis C.) constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence D.) incontinent bowel related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

D.) incontinent bowel related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Explanation: The most appropriate nursing concern addresses the client's fecal incontinence, related to loss of sphincter control innervation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1443.

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? A.) soap B.) normal saline C.) water D.) oil

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1439.

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? A.) increases the volume of the stool, making defecation easier B.) provides an outlet for diarrhea to be funneled into a collection unit C.) softens and facilitates the removal of intestinal polyps D.) removes hardened fecal impactions from the rectum

D.) 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1481.

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

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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1454.

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. True False

False Explanation: Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70 to 130 ml). These solutions draw water into the colon, which stimulates the defecation reflex. Oil retention enemas lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 ml of solution is administered to adults. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1440.

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order. Palpation Inspection Percussion Auscultation

Inspection Auscultation Percussion Palpation Explanation: When assessing a client's abdomen, the correct order for assessment is inspection, auscultation, percussion, and palpation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1426.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? A.) The client consumes large quantities of fresh vegetables. B.) The client returned from a foreign country 2 days ago. C.) The client has a daily fluid intake of 2,000 to 3,000 ml. D.) The client repeatedly ignores the urge to defecate.

The client returned from a foreign country 2 days ago. Explanation: Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 ml of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 38: Bowel Elimination, p. 1422.