Chapter 29

A day after abdominal surgery, a postoperative patient on a surgical unit says to the nurse, "I'm having a problem with a lot of gas. Maybe it's the food I'm eating." What is the appropriate response by the nurse? Select all that apply.

"If the problem continues after you go home, you'll need to avoid gas-producing foods, such as beans." "Let's get you out of bed and walking more. This can help with your gas." "When was your last bowel movement? You may be a bit constipated."

The nurse is caring for a patient on the medical-surgical unit. The patient states, "I really don't like to talk about my bowel movements, but what is considered normal for bowel movements?" What is the best response by the nurse? Select all that apply.

"We can say normal frequency is anything from several times a day to once per week. It depends on your normal pattern." "We also consider whether you have to strain with bowel movements, use laxatives, or have to rush to the toilet."

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Select all that apply.

2 in. (5.1 cm) 3 in. (7.6 cm)

Considering normal developmental and physical maturation in children, for which age would a goal of "Achieves bowel control by the end of this month" be most realistic?

3 years

The nurse instilled 60 mL of irrigant into an indwelling fecal drainage device. The client's output was 140 mL. What would the nurse chart as the client's output of stool?

80 mL

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching?

A stoma that is pale, dusky, or black in color

A patient with severe hemorrhoids is incontinent of liquid stool. Which intervention is contraindicated?

Apply an indwelling fecal drainage device.

The nurse is seeing a patient at home with a new colostomy. In formulating the plan of care, what is the priority goal for this patient? The patient will:

Assume self-care in colostomy management

The nurse is performing an abdominal assessment on a client with irritable bowel syndrome. The nurse has just finished inspection of the abdomen. Which action should the nurse take next?

Auscultate for bowel sounds

The nurse is obtaining a bowel elimination history from an 80-year-old patient. The patient states, "Sometimes when I go to the bathroom, I push real hard, hold my breath, and plug my nose." Which action should the nurse take first?

Check the patient's medical history for heart disease or glaucoma.

A patient who has been immobile since sustaining injuries in a motor vehicle accident reports passing hard stools. The nurse encourages the patient to increase daily fluid intake. Which fluids should the patient avoid because of the diuretic effect? Select all that apply.

Coffee Tea

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?

Collect a stool specimen that contains 20 to 30 mL of liquid stool.

Which tasks may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.

Collecting and testing a stool sample for occult blood Assisting with placing a fracture pan on an immobile patient Changing a preexisting, stable ostomy appliance

The nurse is preparing a patient for an invasive diagnostic test that will provide direct visualization of the rectum, entire large intestine, and distal small bowel. The nurse should teach and give the patient written instructions about which test?

Colonoscopy

In advising an older adult who takes laxatives regularly, the nurse would identify which of the following factors? Select all that apply.

Consistent use of laxatives is thought to cause, rather that cure, constipation. Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly. Chronic laxative use can lead to dependency on the medication.

A male patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally every 12 hours. The patient reports that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?

Consume yogurt daily while taking the antibiotic.

The nurse is performing a focused bowel assessment on an older adult. Which physiological changes of aging should alert the nurse to an increased risk for problems associated with bowel elimination? Select all that apply.

Decreased sphincter control Decreased peristalsis

When changing a diaper, the nurse observes that a 2-day-old infant has passed green-black, tarry stools. What should the nurse do?

Do nothing; this is normal.

The pediatric nurse educator is teaching a group of parents about distinguishing between food allergies and food intolerance. The nurse should teach parents that which food items are considered to be true food allergens? Select all that apply.

Egg whites Shellfish Peanuts

The mother of a 3-month-old infant comes to emergency department and states, "My baby has been having severe diarrhea for 4 days. She is crying all the time." In formulating the plan of care for diarrhea, the nurse focuses outcomes on which of the following? Select all that apply.

Fluid management Electrolyte balance Skin integrity

The community health nurse is preparing a teaching plan on food choices that promote normal bowel elimination. Which foods should the nurse teach participants to be sure to include in their diet? Select all that apply.

Fresh fruits Whole-grain cereals Peas

The nurse is caring for a patient who has a continent ileostomy. Which intervention will the nurse add to the plan of care?

Insert a tube into the stoma to drain the pouch.

A client has a history of chronic constipation. Which medications prescribed for the client would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventive measures? Select all that apply.

Iron Pain medications

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to

Irrigate the stoma to produce a bowel movement on a schedule

The registered nurse is working on a medical-surgical floor. Which behavior by a licensed practical nurse (LPN) would cause the nurse to intervene immediately?

Irrigates an ileostomy

In which area is the appendix located?

Off of the cecum

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication?

Paralytic ileus

Which populations are considered high risk for the development of hemorrhoids? Select all that apply.

Pregnant women School bus drivers Desk job workers

Which action should the nurse tell the parent to take to assess a 2-year-old child for pinworms?

Press clear cellophane tape against the rectum as soon as the child wakes up.

A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient's care plan?

Risk for Constipation

Which factors place the patient at risk for constipation? Select all that apply.

Sedentary lifestyle High-dose calcium supplements

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily.

The nursing instructor is teaching students how to use a fracture pan for patients. What are the most appropriate instructions for this procedure? Select all that apply.

Use for patients with a total hip replacement. Place the wide, rounded end of the pan toward the front of the patient. Assist the patient to a side-lying position prior to placing the bedpan.

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test?

Vitamin C

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing?

Yogurt