Chap 38 Bowel Elimination
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? "Certain vegetables can cause flatus, as they are more difficult to digest." "Parasites in your stool can cause persistent flatus." "Drinking alcoholic beverages can cause flatus." "Flatus is a natural action and the cause is unknown."
"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. Chapter 38: Bowel Elimination - Page 1449
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?" "Are you experiencing rectal fullness?" "Do you use laxatives?" "Is the stool difficult to pass?"
"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. Chapter 38: Bowel Elimination - Page 1421-1425
A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct? "I will administer up to three enemas as prescribed." "I will administer enemas until the enema return is without stool." "You will need to have enemas unless you can consume clear liquids without nausea." "This enema will assist in your bowel regimen when you go home."
"I will administer enemas until the enema return is without stool." Explanation: "Enemas until clear" means that the nurse would administer enemas until no more stool is noted on output. A nurse would not be able to determine if the entire intestinal tract is clear. Administering three enemas is not what the prescriber ordered. Consuming clear liquids does not impact the use of enemas. The enema may not be part of the client's discharge instructions. Chapter 38: Bowel Elimination - Page 1438-1439
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? "I will need yearly screenings for colon cancer." "I will have a fecal occult blood test done every 5 years." "I will have a flexible endoscopic exam done every 5 years." "My mother had colon cancer so I am at a greater risk for also developing colon cancer."
"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. Chapter 38: Bowel Elimination - Page 1429
An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response? "This is good to help bowels move." "Perhaps you should do this twice daily." "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." "It is important that you discontinue this type of treatment immediately."
"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. Chapter 38: Bowel Elimination - Page 1435
The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply. "The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care." "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 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. Chapter 38: Bowel Elimination - Page 1447
A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer analgesia 30 minutes before the procedure. Administer the solution gradually over 5 to 10 minutes.
Administer the solution gradually over 5 to 10 minutes. Explanation: 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. Chapter 38: Bowel Elimination - Page 1453-1456
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? Turn off the suction for 30 minutes and then turn it on again. Attempt to irrigate the NG tube with water or normal saline. Instill digestive enzymes, as ordered. Remove the NG tube and replace it with a larger-bore tube, as ordered.
Attempt to irrigate the NG tube with water or normal saline. Explanation: A nasogastric (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. Chapter 38: Bowel Elimination - Page 1465-1467
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? Measure abdominal girth. Ask when the client last had a bowel movement. Observe the abdominal dressing. Auscultate for bowel sounds.
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. Chapter 38: Bowel Elimination - Page 1426
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? Place the client in a protective supine position to facilitate easy removal. Before removing the tube, discontinue suction and separate the tube from suction. Attach a syringe and flush with 50 mL of water or normal saline before removal. Quickly and carefully remove tube while the client breathes out.
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. Chapter 38: Bowel Elimination - Page 1463-1465
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? Administer an oral analgesia 30 to 45 minutes before attempting insertion. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point. Position the bed flat and assist the client onto his or her left side.
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. Chapter 38: Bowel Elimination - Page 1457-1462
A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? Collect 15 to 30 mL of the client's liquid stool. If portions of the stool include visible blood, mucus, or pus, discard the stool. If the specimen contains barium or enema solution, document this on the container. Refrigerate the specimen until it is cooled before sending it to the laboratory.
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. Chapter 38: Bowel Elimination - Page 1428-1429
A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response? Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. Corn is high in sucrose, which is an insoluble fiber that the body cannot digest. Corn is high in lactose, which is an insoluble fiber that the body cannot digest. Corn is high in galactose, 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. 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. Chapter 38: Bowel Elimination - Page 1449
Which symptom is a known side effect of antibiotics? Diarrhea Constipation Fecal impaction Abdominal bloating
Diarrhea Explanation: A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics. Chapter 38: Bowel Elimination - Page 1437
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? Fecal Incontinence r/t decreased muscle tone and sphincter control Risk for Impaired Skin Integrity r/t fecal incontinence Risk for Disturbed Body Image r/t fecal incontinence Diarrhea r/t decreased muscle tone and sphincter control
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. Chapter 38: Bowel Elimination - Page 1433
Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? Digital removal of stool may cause parasympathetic stimulation. Nurses find the procedure distasteful and difficult to perform. Most clients will not consent to have digital removal of stool. It often causes rebound diarrhea and electrolyte loss.
Digital removal of stool may cause parasympathetic stimulation. Explanation: The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss. Chapter 38: Bowel Elimination - Page 1454
A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take? Facilitate a more private setting, such as assisting the client to a bathroom. Administer a normal saline enema after obtaining the relevant order. Obtain a diet change order to increase the amount of fiber in the client's meals. Position the client on his side and administer a glycerin suppository.
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. Chapter 38: Bowel Elimination - Page 1441
A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. Replace the NG tube if the client experiences nausea within 6 hours of removal. If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied.
If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. Explanation: 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 (bleeding from the nose) occurs with removal of the NG tube, occlude(block) both nares(2 holes of nose) 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. Chapter 38: Bowel Elimination - Page 1463-1465
Which medication causes constipation? Magnesium antacids Bisacodyl Aspirin Iron supplements
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. Chapter 38: Bowel Elimination - Page 1422
The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? Right lateral Left lateral Prone Semi-Fowler's
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. Chapter 38: Bowel Elimination - Page 1430
A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? Palpation Percussion Auscultation Inspection
Palpation Explanation: The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation. Chapter 38: Bowel Elimination - Page 1426
The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? Position the client on his back and drape properly. Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Introduce solution quickly over a period of 3 to 5 minutes. Encourage the client to hold the solution for at least 20 minutes.
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. Chapter 38: Bowel Elimination - Page 1439
The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the physician. Stop the administration of the enema momentarily. Increase the flow of the enema until all of the solution has been administered.
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 physician. Chapter 38: Bowel Elimination - Page 1455
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? Stop the procedure and reposition the client. Slow the infusion rate, have the client take deep breaths, then resume the enema. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. Stop the procedure, monitor heart rate and blood pressure.
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. Chapter 38: Bowel Elimination - Page 1439
The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? The graduate advises the client that the enema should not be expelled immediately. The graduate uses a room temperature solution. The graduate places the client in Fowler's position. The graduate takes this opportunity to teach about the function of the intestinal tract.
The graduate places the client in Fowler's position. Explanation: Placing the client in Fowler's position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it. Chapter 38: Bowel Elimination - Page 1440
A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity? Wash it with a mild cleanser and water. Avoid using commercial skin preparations. Clean it with a dry, cotton bandage. Avoid applying a barrier substance.
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. Chapter 38: Bowel Elimination - Page 1471
Which factor is related to developmental changes in bowel habits for older adult clients? Increase in dietary fiber can decrease peristalsis. Milk products cause constipation in clients with lactose intolerance. Weakened pelvic muscles lead to constipation. Older adults should peel fruits before eating.
Weakened pelvic muscles lead to constipation. Explanation: 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. Chapter 38: Bowel Elimination - Page 1421
Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk? Using a tongue depressor to access stool Taking sample directly from commode insert Wearing disposable gloves Not removing commode insert from commode
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. Chapter 38: Bowel Elimination - Page 1428
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? Asparagus and turnip Fish and dried lentils Yogurt and buttermilk Onions and garlic
Yogurt and buttermilk Explanation: Buttermilk, parsley (herb) , and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor. Chapter 38: Bowel Elimination - Page 1449
For which client would digital removal of stool be contraindicated? a client recovering from prostate surgery a diabetic client with renal complications a client with a spinal cord injury a client with a urinary tract infection
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. Chapter 38: Bowel Elimination - Page 1441
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. Chapter 38: Bowel Elimination - Page 1427
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? cleansing enema retention enema carminative enema return-flow enema
cleansing enema Explanation: The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus. Chapter 38: Bowel Elimination - Page 1439
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? barium studies, endoscopic examination, fecal occult blood test fecal occult blood test, barium studies, endoscopic examination barium studies, fecal occult blood test, endoscopic examination endoscopic examination, barium studies, fecal occult blood test
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. Chapter 38: Bowel Elimination - Page 1432
A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? hemorrhoids diarrhea paralytic ileus constipation
hemorrhoids Explanation: Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles. Chapter 38: Bowel Elimination - Page 1419
The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel? tap water mineral oil water, soap hypertonic saline
hypertonic saline Explanation: The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue. Chapter 38: Bowel Elimination - Page 1439
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? mineral oil tap water soap and water hypertonic saline
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. Chapter 38: Bowel Elimination - Page 1439-1440
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? high intake of fiber constant urges to defecate inadequate intake of liquid constant physical activity
inadequate intake of liquid Explanation: Primary constipation results from lifestyle factors such as insufficient fluid intake, inadequate intake of fiber, inactivity, or ignoring the urge to defecate. Chapter 38: Bowel Elimination - Page 1433
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? water soap normal saline oil
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. Chapter 38: Bowel Elimination - Page 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? increases the volume of the stool, making defecation easier removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps
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. Chapter 38: Bowel Elimination - Page 1481
The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? blood pressure 130/80 mm Hg temperature 99.9°F (37.9°C) skin turgor response 5 seconds heart rate 90 beats/min
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. Chapter 38: Bowel Elimination - Page 1436
A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma? saline mineral oil water and mild soap alcohol-based sanitizer
water and mild soap Explanation: The nurse will teach the client to use water and mild soap to cleanse the stoma. Saline only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing. Reference: Chapter 38: Bowel Elimination - Page 1471
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." "That's correct, but be sure that you don't increase your laxative doses over time."
"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. Chapter 38: Bowel Elimination - Page 1420
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? "Stool cannot be collect from a child's diaper." "Stool can be collected only from a cloth diaper." "It depends on which testing developer is used." "Only if the stool has not been contaminated by urine."
"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. Chapter 38: Bowel Elimination - Page 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? "This test will determine whether foods are contributing to rectal bleeding." "This test will show if you have colorectal cancer." "This test will show if you have an infection in the bowel." "This test detects heme, a type of iron compound in blood in the stool."
"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. Chapter 38: Bowel Elimination - Page 1429
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? 20-30 g 40-50 g 60-70 g >80g
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. Chapter 38: Bowel Elimination - Page 1422
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? 3 in (7.5 cm) 1 in (2.5 cm) 2 in (5.0 cm) 5 in (12.5 cm)
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. Chapter 38: Bowel Elimination - Page 1419
The nurse is talking with four members of a family. Which client within the family does the nurse identify that would benefit from discussing a colonoscopy screening with their health care provider? 18-year old who with diarrhea twice weekly 22-year old who experiences constipation 47-year old whose father had polyps 48-year old with regular bowel habits
47-year old whose father had polyps Explanation: Colonoscopy screenings should begin at the age of 50 and continue every 10 years thereafter. The 47-year old with a family history of polyps should discuss a colonoscopy screening with the health care provider. Other answers are incorrect. Chapter 38: Bowel Elimination - Page 1428
The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? 33-year-old client who reports painful elimination 42-year-old client with diarrhea twice weekly 50-year-old client with a family history of polyps 67-year-old client with constipation
50-year-old client with a family history of polyps Explanation: 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. Chapter 38: Bowel Elimination - Page 1428-1429
For which client would a hypertonic enema most likely be contraindicated? A client who is severely constipated A client with renal impairment A client who has peripheral edema A client with type 1 diabetes
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. Chapter 38: Bowel Elimination - Page 1439
The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? Antiflatulence agent Antidiarrheal agent Laxative Suppository
Antidiarrheal agent Explanation: Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects. Chapter 38: Bowel Elimination - Page 1437
An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis
Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Explanation: The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation. Chapter 38: Bowel Elimination - Page 1443
Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet? Custard Chicken Lettuce salad Baked potato
Custard Explanation: The client should not be permitted to eat the custard because it is prepared using milk. Clients who are lactose intolerant cannot digest the simple sugar lactose found in milk and milk products. Chicken is a protein. Lettuce and potato are vegetables. Chapter 38: Bowel Elimination - Page 1422-1423
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.
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. Chapter 38: Bowel Elimination - Page 1426
A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? Emptying a client's ileostomy appliance Assessing a client's GI system Inserting a client's NG tube Irrigating a client's NG tube
Emptying a client's ileostomy appliance Explanation: It is safe for an experienced UAP to empty an ostomy. GI assessment and insertion and irrigation of an nasogastric (NG) tube cannot be delegated. Chapter 38: Bowel Elimination - Page 1468-1473
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? Advise decreasing dietary fiber in the diet to enhance stooling. Advise increasing milk or milk products in the diet to provide stool bulk. Encourage physical activity to improve bowel regularity. Suggest use of warm compresses on the abdomen to increase gastrointestinal motility.
Encourage physical activity to improve bowel regularity. Explanation: 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. Chapter 38: Bowel Elimination - Page 1421
Which statement about ostomy irrigation is true? For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Daily irrigation is necessary to assure passage of stool from an ileostomy. Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery.
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. Chapter 38: Bowel Elimination - Page 1448
The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? Bacon Eggs Whole milk Grapefruit
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. Chapter 38: Bowel Elimination - Page 1422
Which medical diagnosis is most likely to necessitate testing for fecal occult blood? Peptic Ulcer Chronic Constipation Cirrhosis of the Liver Gastroesophageal Reflux Disease (GERD)
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. Chapter 38: Bowel Elimination - Page 1428
A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include? Plans to eat 4 ounces of protein 3 times per day. Will includes a pat of butter with eggs for breakfast. Plans to eat a snack of fruit twice per day. Will include fish one to two times per week.
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. Chapter 38: Bowel Elimination - Page 1422-1423
The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration? Sims prone supine semi-Fowlers
Sims Explanation: Sims position is appropriate as it promotes gravity distribution of the solution. Other choices are incorrect positions. Chapter 38: Bowel Elimination - Page 1454
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? prone supine semi-Fowler's Sims
Sims Explanation: Sims position is appropriate for a client who will receive this type of enema, as it promotes gravity distribution of the solution. Other choices are incorrect positions. Chapter 38: Bowel Elimination - Page 1454
When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? The stoma is pink. The stoma has a small amount of bleeding. The stoma is prolapsed. The stoma is on the abdominal surface.
The stoma is prolapsed. Explanation: 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. Chapter 38: Bowel Elimination - Page 1446
The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? Use water only. Use alcohol-based sanitizer. Use water and mild soap. Use mineral oil.
Use water and mild soap. Explanation: The nurse will teach the client to use water and mild soap to cleanse the stoma. Water only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing. Chapter 38: Bowel Elimination - Page 1471
A student nurse studying human anatomy knows that a structure of the large intestine is the: duodenum jejunum ileum cecum
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. Chapter 38: Bowel Elimination - Page 1419
A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? dark pink and moist red and dry off-white or pale pink. dark or purple-blue.
dark pink and moist Explanation: A healthy stoma is dark pink to red and moist. Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia. Chapter 38: Bowel Elimination - Page 1447
A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? left side-lying prone right side-lying supine
left side-lying Explanation: When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up, and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client, not for an enema. Chapter 38: Bowel Elimination - Page 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: bloody. mucus-filled. soft semi-formed. liquid consistency.
liquid consistency. Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes. Chapter 38: Bowel Elimination - Page 1445