Foundations Chapter 37 Bowel Integrity

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."

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

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

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

-"I can go about my daily routine while the camera is passing though my small intestine."

A client is taking home occult blood testing (FOBT) supplies. Which client statement requires nursing intervention? -"I will not take any Tylenol 7 days prior to testing." -"I will drink juice and water to stay hydrated after doing the test." -"I like to eat beef, so this will be good for me before performing the test." -"I can eat plenty of chicken to get plenty of protein."

-"I like to eat beef, so this will be good for me before performing the test." The client should avoid eating red meat 3 days before testing, as well as refrain from consuming citrus fruits or juices for 3 days before beginning the test. Acetaminophen use is acceptable; nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided 7 days before self-collecting stool. Eating chicken is acceptable.

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."

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." 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.

The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply. -"The muscles of the colon are innervated by the endocrine system." -"Vitamins D and E are produced by the bacteria action in the large intestines." -"Movement of the colon is stimulated by the parasympathetic nervous system." -"The last part of the large intestine is the rectum, not the anus." -"The stool becomes hard if it remains in the large intestine too long."

-"Movement of the colon is stimulated by the parasympathetic nervous system." -"The last part of the large intestine is the rectum, not the anus." -"The stool becomes hard if it remains in the large intestine too long." Vitamin K and some of the B-complex vitamins are produced by bacterial action in the large intestine.

The nurse is caring for a client that reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that they feel dizzy. What should the nurse educate the client about this condition? -"This happens when you bear down causing an increase in blood volume to the heart and will result in your heart rate becoming too rapid." -"This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart." -"This occurs when bearing down and decreasing blood flow to the heart then when you stop, the blood flow returns in larger amount." -"There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement."

-"This occurs when bearing down and decreasing blood flow to the heart then when you stop, the blood flow returns in larger amount."

A client has been given Cologuard testing supplies. What teaching will the nurse provide about the purpose for this test? -"This will determine what foods you are allergic to that affect digestion and elimination." -"This test detects mutant DNA from tumor cells present in stool." -"This test detects heme, an iron compound in blood within the stool." -"This test will help determine whether you have an infectious process in the intestines."

-"This test detects mutant DNA from tumor cells present in stool." It does not test for allergic foods, nor does it test for infection. FOBT detects heme.

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 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.

The postpartum nurse is instructing a new mother that her infant will pass meconium for: -1 day -2 days -3 days -4 days

-3 days By the 3rd day after birth, the stool's characteristics begin to reflect the type of milk in the diet.

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 inches (7.5 cm) -1 inch (2.5 cm) -2 inches (5.0 cm) -5 inches (12.5 cm)

-3 inches (7.5 cm)

The nurse is providing health teaching for four clients. Which client will the nurse teach that 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

Which client is most likely to require interventions in order to maintain regular bowel patterns? -A client whose neuropathic pain requires multiple doses of opioids each day. -A client with hypertension who takes a diuretic and adrenergic blocker each morning. -A client who has a history of atrial fibrillation requiring daily anticoagulants. -A woman 59 years of age who has recently begun hormone replacement therapy.

-A client whose neuropathic pain requires multiple doses of opioids each day.

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation? -Reduces elasticity in intestinal walls and slows motility -Affects absorption of fat-soluble vitamins -Causes periodic bleeding and tissue trauma -Develops healthier bowel elimination patterns

-Affects absorption of fat-soluble vitamins

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation? -Reduces elasticity in intestinal walls and slows motility -Affects absorption of fat-soluble vitamins -Causes periodic bleeding and tissue trauma -Develops healthier bowel elimination patterns

-Affects absorption of fat-soluble vitamins

The client reports taking bisacodyl daily for several weeks and remains constipated. What are appropriate actions of the nurse? Select all that apply. -Ask the client about abdominal pain. -Auscultate the abdomen for bowel sounds. -Assess the client's diet and fluid intake. -Instruct the client to continue taking bisacodyl until the medication produces a bowel movement. -Question the client about the color, consistency, pattern, and shape of stools. -Tell the client to increase fiber intake and keep fluid intake the same.

-Ask the client about abdominal pain. -Auscultate the abdomen for bowel sounds. -Assess the client's diet and fluid intake. -Question the client about the color, consistency, pattern, and shape of stools. The nurse would complete an assessment when a client reports daily intake of bisacodyl, a stimulant laxative that is addictive. Assessments would include asking about abdominal pain, diet, fluid intake, and stool. The nurse would perform a physical assessment that would include auscultating for bowel sounds, which would indicate peristalsis. The nurse would ask the client to discontinue the medication that is ineffective and initiate a bowel training program. The bowel training program would include increasing fiber and fluid intake, not keeping the fluid intake the

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client? -Assess the color of the stoma. -Apply device for stool collection. -Perform stoma irrigation. -Have the client perform self stoma care

-Assess the color of the stoma. A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.

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? -Room temperature -Chilled -Warm -In fruit juice

-Chilled

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

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

The nurse has assessed the client, analyzed the data, and identified constipation as a client problem. Which assessment data would support constipation? Select all that apply. -Client reports frequency of daily bowel movements as every 3 to 4 days. -Client states straining when having a bowel movement. -Stool is hard and has a consistency of small "marbles." -Client reports urgency when needing to have a bowel movement. -Bowel sounds are hyperactive in all four quadrants.

-Client reports frequency of daily bowel movements as every 3 to 4 days. -Client states straining when having a bowel movement. -Stool is hard and has a consistency of small "marbles."

A nurse who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply. -Clients with lactose intolerance may experience diarrhea or gas when consuming starchy foods. -A client who is constipated should eat eggs and pasta to relieve the condition. -Clients who are constipated should eat more fruits and vegetables. -Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. -Alcohol and coffee tend to have a constipating effect on clients. -Clients with food intolerances may experience altered bowel elimination.

-Clients who are constipated should eat more fruits and vegetables. -Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. -Clients with food intolerances may experience altered bowel elimination.

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? -Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. -Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. -Provide a light meal before the test and administer two Fleet enemas. -Ensure that the client fasts 6 to 12 hours before the test as per policy.

-Ensure that the client fasts 6 to 12 hours before the test as per policy.

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.

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

-False A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. T or F

-False Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70-130 mL). These solutions draw water into the colon, which stimulates the defecation reflex. Oil-retention enemas: lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 mL of solution is administered to adults.

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. 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.

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag? -Liquid -Watery -Formed -None

-Formed

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag? -Liquid -Watery -Formed -None

-Formed

A nurse is providing home care for a client with fecal incontinence. Which suggestions should the nurse give the client and family when managing fecal incontinence? Select all that apply. -Have the client use moisture-proof undergarments. -Encourage the client to limit fiber intake. -Ask the client to monitor the pattern of incontinence. -Eat nutritious foods regularly -Have the client pull the abdomen inward and exhale.

-Have the client use moisture-proof undergarments.

A nurse is providing home care for a client with fecal incontinence. Which suggestions should the nurse give the client and family when managing fecal incontinence? Select all that apply. -Have the client use moisture-proof undergarments. -Encourage the client to limit fiber intake. -Ask the client to monitor the pattern of incontinence. -Eat nutritious foods regularly -Have the client pull the abdomen inward and exhale.

-Have the client use moisture-proof undergarments. -Ask the client to monitor the pattern of incontinence. -Eat nutritious foods regularly

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. -Help the client into a Sims' position. -Cool the container holding the solution. -Compress the container as the solution instills. -Wipe the lubricated tip of the container before insertion. -Encourage the client to retain the solution.

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

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? -Visible waves of abdominal peristalsis -Hyperactive bowel sounds -Increased anal area pigmentation -Dry, hard stool

-Hyperactive bowel sounds

The nurse understands that which client diversion is considered a continent ostomy? -Colostomy -Ileostomy -Ileal conduit -Ileoanal

-Ileoanal A continent fecal diversion is the ileoanal diversion. With this type of diversion, feces can be drained at the client's convenience rather than having it continually draining into an external pouch, as occurs in the traditional ileostomy or colostomy.

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

-Inspection -Auscultation -Percussion -Palpation

The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client? -Keep the client's bed in the lowest position. -Encourage the client to eat fresh fruits and vegetables. -If diarrhea is still present after 48 hours, continue giving diphenoxylate and atropine. -Check with health care provider before giving diphenoxylate and atropine to a child.

-Keep the client's bed in the lowest position. Diphenoxylate and atropine may cause drowsiness, so the client is at risk for falls. The bed should be kept in its lowest position. Clients should avoid foods such as fresh fruits and vegetables as these foods are high in fiber; this client needs a low-fiber diet. Diphenoxylate and atropine should be discontinued if it has no effect on the diarrhea in 48 hours. Diphenoxylate and atropine do not contain aspirin, so the nurse need not check with the health care provider before administering.

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 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.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? -Remove the tubing and discontinue the procedure. -Lower the solution container and check the temperature and flow rate. -Place the client on a bedpan in the supine position while receiving the enema. -Reposition the rectal tube and check for any fecal content.

-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. A client should not be placed on a bedpan until after the rectal tube is removed

Which enema solution lubricates the stool and intestinal mucosa without distending the intestine? -Water -Soap -Normal saline -Oil

-Oil

An older adult client has a history of constipation and currently self-treats with over-the-counter laxatives. What should the nurse educate the client regarding the use of laxatives? Select all that apply. -All older adults should use laxatives to promote normal defecation. -Oral laxatives take longer to effect change than laxatives administered rectally. -Older adults are at particular risk for laxative abuse. -Rectal suppositories tend to work within 60 minutes of administration. -It will be helpful to increase dietary fiber and fluids.

-Oral laxatives take longer to effect change than laxatives administered rectally. -Older adults are at particular risk for laxative abuse. -Rectal suppositories tend to work within 60 minutes of administration.

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

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

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time? -Save a sample of the stool in a container. -Perform a screening test on stool samples. -Send the stool sample to the laboratory. -Inform the client to report the occurrence if it happens again.

-Perform a screening test on stool samples.

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

-Place the client on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. If the client cannot retain the enema solution for an adequate amount of time, place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort. If still unable to retain the solution, notify the physician. The nurse does not need to reposition the rectal tube but needs to assist the client by repeating the procedure with a slight variation.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide? -Avoid acetaminophen 7 days prior to testing. -Drink orange juice to stay hydrated through the testing process. -Refrain from eating red meat 3 days before testing. -Eat plenty of raw vegetables before testing.

-Refrain from eating red meat 3 days before testing.

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next? -Measure the stoma using a stomal guide. -Fold and clamp bottom of pouch. -Attach new pouch to the ring of the faceplate. -Shower, bathe, or wash peristomal area with mild soapy water.

-Shower, bathe, or wash peristomal area with mild soapy water.

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

-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.

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. 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.

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply. -The client has a history of chronic renal failure. -The client has an elevated glucose level. -The client has an elevated phosphorus level. -The client is lactose intolerant. -The client has a history of left sided heart failure.

-The client has a history of chronic renal failure. -The client has an elevated phosphorus level. -The client has a history of left sided heart failure.

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

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

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

-The client takes bisacodyl every day. Overusage of bisacodyl may cause lazy bowel syndrome, leading to constipation

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed? -The student had the client flex the knees when performing the assessment. -The student sequenced from auscultation to inspection, and percussion to palpation. -The student placed the client in supine position with the abdomen exposed. -The student instructed the client to urinate before beginning the focused assessment.

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

An older adult client immigrated from the Middle East and speaks very little English. The client reports blood in the stool but is treating it with a mixture of herbs imported from the clients home country. Which statements apply to this client? Select all that apply. -Treatment for bowel changes with folk remedies is a common practice. -The client may be reluctant to discuss bowel movements in front of a health care provider of the opposite sex. -The client's family member can be used to interpret because of the personal nature of the concern. -The client should continue to use folk remedies and return in 6 months for follow up. -The client should be informed that discontinuation of all folk remedies is essential

-Treatment for bowel changes with folk remedies is a common practice. -The client may be reluctant to discuss bowel movements in front of a health care provider of the opposite sex.

The nurse is preparing a client for a guaiac fecal occult blood test. What medications taken by the client does the nurse identify that may cause a false-positive result in the test? Select all that apply. -Warfarin 10 mg daily -Ferrous sulfate 325 mg daily -Metoprolol 25 mg daily -Furosemide 40 mg daily -Prednisone 20 mg daily

-Warfarin 10 mg daily -Ferrous sulfate 325 mg daily -Prednisone 20 mg daily Certain medications, such as a salicylate intake of more than 325 mg daily, other nonsteroidal anti-inflammatory drugs, steroids, iron preparations, and anticoagulants, also may lead to false-positive readings. Furosemide and metoprolol do not have any affect on the results of the test.

The nurse is caring for a client prescribed a hypertonic saline solution enema. The nurse deterrmines that the enema would be contraindicated for: -a client who is constipated. -a client with renal impairment. -a client who has gastroesophageal reflux disease (GERD). -a client who has cancer.

-a client with renal impairment.

The proliferation of Clostridium difficile causes: -antibiotic-associated diarrhea. -Escherichia coli diarrhea. -Urinary Clostridium infection. -anal yeast infection.

-antibiotic-associated diarrhea.

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

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate? -stopping the infusion -removing the tubing immediately -reassuring the client that cramping is normal -briefly clamping the tubing while the client breathes deeply

-briefly clamping the tubing while the client breathes deeply

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

-dark brown -light brown

An older adult client who is wheelchair bound following a cerebrovascular accident is being assessed by the nurse. The nurse notes the client has seepage of stool from the anus. What does the nurse identify may be the clients condition? -constipation. -diarrhea. -fecal impaction. -intestinal infection.

-fecal impaction.

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply. -hot tea with meals -a turkey sandwich with whole-grain bread -prune juice with breakfast -ice cream with lunch and dinner -diet soda with lemon

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

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

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

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs? -large-volume cleansing enema with hypotonic solution -small-volume cleansing enema with hypotonic solution -small-volume cleansing enema with isotonic solution -large-volume cleansing enema with oil

-large-volume cleansing enema with hypotonic solution Large-volume cleansing enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying.

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

-lentils -onions -cabbage

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed? -distends rectum and moistens stool -distends rectum and irritates local tissue -irritates local tissue -lubricates and softens stool

-lubricates and softens stool

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

-physiologic or lifestyle changes in the client.

The nurse is caring for a client on bed rest who has constipation. How will the nurse document this finding? -primary constipation -secondary constipation -iatrogenic constipation -pseudoconstipation

-primary constipation The nurse will document this finding as primary constipation, which results from lifestyle factors such as inactivity.

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 Enemas are not used for diarrhea.

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

-secondary constipation

A 7-month-old infant recently underwent a bowel resection for an isolated perforation. The surgeons removed most of the client's ileum. The remaining small intestine was spared, and the large intestine remains intact. Based on the nurse's knowledge of digestion, the nurse knows that the client will likely have problems with which type of nutrient absorption? -some vitamins and iron -electrolytes -fluid -all nutrients

-some vitamins and iron Some vitamins and iron are absorbed in the ileum, along with a small amount of fluid. However, most of the fluid is absorbed in the large intestine. Electrolytes are predominantly absorbed in the duodenum, jejunum, and large intestine.

A nurse is caring for a 65-year-old woman who has undergone a hernia operation. The client has a morphine PCA for postoperative pain. She also receives sulfamethoxazole-trimethoprim every 12 hours to treat a urinary tract infection, and an iron supplement for anemia. The client is on mobility restrictions because of the narcotics. She explains that while she usually stools once per day, she has stooled four times today. What is most likely contributing to her diarrhea? -morphine -iron supplement -immobility -sulfamethoxazole-trimethaprim

-sulfamethoxazole-trimethaprim

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be ordered? -vitamin A -vitamin B12 -vitamin C -vitamin D

-vitamin B12

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse recognize the client will need? -vitamin A -vitamin B12 -vitamin C -vitamin D

-vitamin B12