Ch 38 - Bowel Elimination

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

A, B, C: age 50 and older; a positive family history; a history of inflammatory bowel disease 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.

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. A. "Have you started a new medication?" B. "What are your normal bowel habits?" C. "Are you experiencing rectal fullness?" D. "Do you use laxatives?" E. "Is the stool difficult to pass?"

A, B, D: "Have you started a new medication?" / "What are your normal bowel habits?" / "Do you use laxatives?" 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.

The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which interventions are appropriate suggestions? Select all that apply. A. Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. B. Apply a commercially available skin barrier before applying the ostomy pouch. C. Secure the ostomy pouch in place by wrapping an elastic bandage around the abdomen, making sure to cover the entire ostomy appliance. D. Leave the ostomy pouch off and cover the stoma with an adult incontinence pad. E. After applying the ostomy pouch, lie flat in the prone position for 10 to 15 minutes to facilitate adhesion.

A, B: Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch; Apply a commercially available skin barrier before applying the ostomy pouch. In cases in which a client's colostomy bag continues to come loose or fall off, the nurse should either perform or recommend that the client do the following: thoroughly cleanse the skin and apply skin barrier. Allow the area to dry completely. Reapply the pouch. Monitor pouch adhesion and change the pouch as soon as there is an adhesion break. Wrapping an elastic bandage around the colostomy pouch would restrict the flow of feces into the pouch and should not be done. The ostomy pouch should not be left off and replaced with an adult incontinence pad, as this would result in leakage. Having the client lie flat in the prone position for 10 to 15 minutes after applying the pouch to facilitate adhesion is not necessary; the nurse simply needs to apply gentle, even pressure to the appliance for about 30 seconds after applying it.

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. A. Watch for liquid bowel movements after days with none. B. Your abdomen will feel empty. C. You will urinate less often or not at all. D. You may experience pain on defecation. E. You will feel less thirsty.

A, D: Watch for liquid bowel movements after days with none; You may experience pain on defecation. Constipation is accompanied by various signs and symptoms, such as pain on defecation, abdominal distention, and changes in the characteristics of stool, such as oozing liquid stool or hard, small stool. A person who is constipated does not report increased bowel movement frequency but a decreased frequency of bowel movements. Clients may report abdominal fullness or bloating and an inability to pass stool, not urine. Constipation will not cause the client to be less thirsty.

A nurse is caring for a client who has a large, hardened mass of stool that is interfering with defecation, making it impossible for the client to pass feces voluntarily. Which recommendation(s) will the nurse provide the client to prevent future fecal impaction from occurring? Select all that apply. A. Increasing fluid intake B. Increasing fat in the diet C. Limiting fluids after bedtime D. Requesting a laxative from the health care provider E. Increasing daytime exercise

A, E: Increasing fluid intake; Increasing daytime exercise The client has fecal impaction because the large, hardened mass of stool is interfering with defecation, making it difficult for the client to pass stool voluntarily. The client will need to prevent constipation by increasing fluid intake, exercising, and toileting at regular intervals. While laxatives can be effective in the short term, they can also cause dependence. Increasing fat in the diet will not help to prevent constipation. Limiting fluids after bedtime will help the client to not have the urge to urinate throughout the night.

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. "I will keep you covered as much as possible during the procedure." B. "You will need to lay completely on your stomach." C. "Do not try to hold the enema in; it will cause pain." D. "Lay flat on your back with your knees pulled to your chest."

A. "I will keep you covered as much as possible during the procedure." 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.

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

A. Assist the client to a 30- to 45-degree position, unless this is contraindicated. 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.

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 cellulose, which is an insoluble fiber that the body cannot digest. B. Corn is high in sucrose, which is an insoluble fiber that the body cannot digest. C. Corn is high in lactose, which is an insoluble fiber that the body cannot digest. D. Corn is high in galactose, which is an insoluble fiber that the body cannot digest.

A. Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. 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.

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

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

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? A. Disconnect the nasogastric tube from suction during the assessment of bowel sounds. B. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. C. Allow the low intermittent suction to continue during the assessment of bowel sounds. D. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

A. Disconnect the nasogastric tube from suction during the assessment of bowel sounds. 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.

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

A. For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. 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.

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. Continue with the enema with no further intervention. C. Digitally stimulate the client to defecate. D. Use a different solution for the enema.

A. Generously lubricate the enema tube tip before proceeding. 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.

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? A. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. B. Replace the NG tube if the client experiences nausea within 6 hours of removal. C. If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. D. If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied.

A. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.

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

A. The NG tube is in the client's airway. 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.

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

A. Wash it with a mild cleanser and water. 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.

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 fruits and vegetables B. a diet lacking in glucose and water C. a diet lacking in refined grains, seeds, and nuts D. a diet lacking in meat and poultry products

A. a diet lacking in fruits and vegetables 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.

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

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

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? A. left side-lying B. prone C. right side-lying D. supine

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

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? A. palpation B. percussion C. auscultation D. inspection

A. palpation The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, 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. A. Ordering the test B. Collecting the specimen C. Handling the specimen D. Transporting the specimen E. Teaching the client about the test F. Planning medical treatment based on test results

B, C, D, E: Collecting the specimen; Handling the specimen; Transporting the specimen; Teaching the client about the test 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.

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

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

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? A. Auscultated abdomen for bowel sounds. Bowel not functioning. B. All four abdominal quadrants auscultated. Bowel sounds absent. C. Bowel sounds auscultated. Client has no bowel sounds. D. Client may have bowel sounds, but they cannot be heard.

B. All four abdominal quadrants auscultated. Bowel sounds absent. The nurse will document what was done during the assessment and note that bowel sounds are absent. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate, because the nurse has diagnosed that the bowel is not functioning, which is a medical diagnosis. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate; it does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they cannot be heard" is a subjective statement and does not document the assessment.

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

B. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. 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.

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. Room temperature B. Chilled C. Warm D. In fruit juice

B. Chilled 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.

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 Crohn's disease B. Client with food poisoning C. Client with a bowel tumor D. Client with alcohol use

B. Client with food poisoning 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.

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 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.

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. Remove the tubing immediately and discontinue the procedure. B. Lower the solution container and check the temperature and flow rate. C. Place the client on a bedpan in the supine position while receiving the enema. D. Reposition the rectal tube and check for any fecal content.

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

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

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 had the client flex the knees when performing the assessment. B. The student sequenced from auscultation to inspection, and percussion to palpation. C. The student placed the client in supine position with the abdomen exposed. 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. 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.

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 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.

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be: A. green. B. yellow. C. beige. D. brown.

B. yellow. If newborns are fed breast milk, the stools will be yellow to gold in color, soft, and unformed with an unobjectionable odor. Dark greenish stool characterizes the first stool after birth, the meconium. Beige and brown stools are characteristic of formula-feed infants.

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. "Perhaps you should do this twice daily." C. "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." D. "It is important that you discontinue this type of treatment immediately."

C. "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." 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.

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? A. "This will determine what foods you are allergic to that affect digestion and elimination." B. "This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." C. "This test detects heme, an iron compound in blood within the stool." D. "This test will help determine whether you have an infectious process in the intestines."

C. "This test detects heme, an iron compound in blood within the stool." The nurse will teach that the FOBT detects heme. It does not test for allergic foods, nor does it test for infection. The fecal immunochemical test (FIT) test results have a high rate of specificity for colorectal cancer.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? A. 33-year-old client who reports painful elimination B. 42-year-old client with diarrhea twice weekly C. 50-year-old client with a family history of polyps D. 67-year-old client with constipation

C. 50-year-old client with a family history of polyps The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk? A. Advise decreasing dietary fiber in the diet to enhance stooling. B. Advise increasing milk or milk products in the diet to provide stool bulk. C. Encourage physical activity to improve bowel regularity. D. Suggest use of warm compresses on the abdomen to increase gastrointestinal motility.

C. Encourage physical activity to improve bowel regularity. Clients at risk for constipation should be encouraged to participate in regular physical activity to increase gastrointestinal motility and improve bowel regularity. Dietary fiber should be increased, not decreased. Milk products can result in constipation. Drinking water is important; however, the amount falls below the recommended amount of daily water intake.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide? A. Avoid acetaminophen 7 days prior to testing. B. Drink orange juice to stay hydrated through the testing process. C. If you have had a recent nose bleed, postpone using test. D. If you have irritated hemorrhoids, this will not alter the results.

C. If you have had a recent nose bleed, postpone using test. When educating a client about using the at home fecal occult blood test (FOBT), the nurse instructs the client to not use laxatives or enemas, postpone if female is menstruating, postpone if hematuria, bleeding hemorrhoids, or blood nose recently. Drinking orange juice can cause false negative results.

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

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

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

C. Plans to eat a snack of fruit twice per day. 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.

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. Places a disposable pad on the work surface B. Empties the pouch before changing the appliance C. Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate D. Applies a skin protectant to a 2-in (5-cm) radius around the stoma and allows it to dry completely

C. Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate 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.

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 for approximately 30 seconds then decrease it to the prior flow rate. B. Stop the administration of the enema and notify the physician. C. Stop the administration of the enema momentarily. D. Increase the flow of the enema until all of the solution has been administered.

C. Stop the administration of the enema momentarily. 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 physician.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the health care provider? A. The stoma is pink. B. The stoma has a small amount of bleeding. C. The stoma is prolapsed. D. The stoma is on the abdominal surface.

C. The stoma is prolapsed. If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.

Which factor is related to developmental changes in bowel habits for older adult clients? A. Increase in dietary fiber can decrease peristalsis. B. Milk products cause constipation in clients with lactose intolerance. C. Weakened pelvic muscles lead to constipation. D. Older adults should peel fruits before eating.

C. Weakened pelvic muscles lead to constipation. Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in older adults. Peeling fruit does not impact bowel habits in the older adults.

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

C. Wearing disposable gloves 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.

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

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

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

C. physiologic or lifestyle changes in the client. 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.

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider? A. the client who has a visual nonbleeding hemorrhoid B. the client who develops dizziness and diaphoresis during administration C. the client who experiences severe abdominal pain D. the client who has an increase in bowel sounds after administration

C. the client who experiences severe abdominal pain Be gentle and lubricate the tip generously before insertion of the enema, but a hemorrhoid is not a reason to stop. When a client experiences dizziness, light-headedness, and sweating, the nurse should slow down the administration of the enema and ask the client to take slow, deep breaths and relax to decrease the symptoms of rapid administration and vagal response. The nurse should stop the enemas with severe abdominal pain, assess bowel sounds, and call the primary care provider because the pain may be a warning sign of trauma to the GI tract or potential perforation of the bowel. It is an expected finding that the enema will stimulate peristalsis.

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. "It depends on which testing developer is used." D. "Only if the stool has not been contaminated by urine."

D. "Only if the stool has not been contaminated by urine." 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.

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 colorectal cancer." C. "This test will show if you have an infection in the bowel." D. "This test detects heme, a type of iron compound in blood in the stool."

D. "This test detects heme, a type of iron compound in blood in the stool." The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? A. Warm the solution for 40 seconds in a microwave to prevent chilling the client. B. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. C. Administer analgesia 30 minutes before the procedure. D. Administer the solution gradually over 5 to 10 minutes.

D. Administer the solution gradually over 5 to 10 minutes. Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

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. 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.

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

D. Clamp the tube for a brief period and resume at a slower rate. 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.

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

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. Whole milk D. Grapefruit

D. Grapefruit 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.

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? A. Place the client on bedpan in the supine position while receiving enema. B. Remove the tube and check for any fecal contents. C. Modify the amount and length of the administration. D. Lower solution container and check temperature and flow rate.

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

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

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

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

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: A. bloody. B. mucus-filled. C. soft semi-formed. D. liquid consistency.

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

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) 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.

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

A. Diarrhea A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.

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 returned from a foreign country 2 days ago. B. The client has a daily fluid intake of 2,000 to 3,000 ml. C. The client consumes large quantities of fresh vegetables. D. The client repeatedly ignores the urge to defecate.

A. The client returned from a foreign country 2 days ago. 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.

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

C, D, E: black; clay colored; yellow 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.

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. Drink orange and grapefruit juice D. Avoid more than 250 mg

D. Avoid more than 250 mg 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.

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

D. Every 4 to 8 hours The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.