(PrepU) Chapter 38: Bowel Elimination

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds." In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.

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?" "Do you use laxatives?" The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

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 enemas until the enema return is without stool." "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.

The nurse is caring for a 68-year-old female client who weighs 108 pounds. The client has been worried about regularity of her bowel movements. The nurse has just placed a regular bedpan under the client and the client states, "Please leave the bedpan in place until I have a bowel movement." Which response is most appropriate?

"I will check back in 10 minutes and remove the bedpan for a period of time even if you have not had a bowel movement." A bedpan should not be left in place for extended periods of time because this can result in excessive pressure and irritation to the client's skin. Telling the client the nurse will return in 10 minutes allows for ample time on the bedpan for results to occur. Telling the client to turn on the call light or staying on the bedpan for an extended period can cause discomfort for the client. For accurate intake and output, the nurse should instruct the client not to urinate in the bedpan.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins." The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation.

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." 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.

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

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

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

The nurse is preparing to administer a hypertonic saline enema. How much should the nurse prepare to administer?

120 mL A hypertonic saline enema should contain 120 mL of solution. Other answers are incorrect, as they represent too much fluid that could overly irritate local tissues and draw too much water into the bowel.

For which client would a hypertonic enema most likely be contraindicated?

A client with renal impairment 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.

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?

Antidiarrheal agent 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.

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 The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

A nurse is irrigating a client's nasogastric tube. Place the following steps in the correct order. Use all options.

Check placement of the nasogastric tube. Draw up 30 mL of irrigation solution into a syringe. Clamp the nasogastric tube near the connection site. Hold the syringe upright, and gently insert the irrigant. Hold the end of the nasogastric tube over an emesis basin. Inject air into the blue air vent. Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged. Drawing up the specified amount of solution into a syringe ensures delivery of the proper amount of irrigant through the tube. Clamping prevents leakage of gastric fluid. Gentle insertion of saline solution (or gravity insertion) is less traumatic to gastric mucosa. Return flow may be collected in an irrigating tray or other available container and measured. This amount needs to be subtracted from the irrigant to record the true nasogastric drainage. Following irrigation, the blue air vent is injected with air to keep it clear.

The nurse needs to assess the client's elimination patterns. Which client will most likely deny the urge to defecate?

Client 3 days' postvaginal birth People who experience pain during defecation may choose to deny the urge to defecate, which can lead to constipation. The client with anxiety and depression typically does not have pain upon defecation. The client with a colostomy will also typically not have pain upon defecation. The client consuming >30 g of fiber will typically not be constipated.

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. 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.

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 cellulose, which is an insoluble fiber that the body cannot digest. However, the body breaks down the other components of corn. Chewing corn for longer can also help the digestive system break down cellulose walls to access more of the nutrients. Sucrose, lactose, and galactose are sugars that are not fiber and more easily digestible by the body. During digestion, starches and sugars are broken down both mechanically (e.g. through chewing) and chemically (e.g. by enzymes) into the single units glucose, fructose, and/or galactose, which are absorbed into the blood stream and transported for use as energy throughout the body.

Which symptom is a known side effect of antibiotics?

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

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

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds. If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do?

Document the output; this is normal. Output from a colostomy is normally formed stool. Therefore the nurse should document the output as normal. There is no need to contact the physician at this time, assess for an obstruction, or give a laxative since the formed stool is normal.

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 fasts 6 to 12 hours before the test as per policy. The nurse would ensure that the client fasted 6 to 12 hours before the test as per policy. The nurse would not provide a light meal before the test, nor administer two Fleet enemas for an EGD. The client would not ingest a gallon of bowel cleanser. The nurse would not give the client a barium contrast mixture to drink.

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. 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.z

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply.

Handwashing is performed before and after glove use when handling a stool specimen. Medical aseptic techniques are always followed. The client should be instructed not to place toilet tissue in the bedpan or specimen container. The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The nurse would ask the client to void first and not to contaminate the stool with any urine. The nurse would ask the client not to place toilet paper in the stool specimen container or bedpan. The nurse would always follow medical aseptic techniques. The nurse would perform handwashing before and after glove use. The nurse would not ask the client to defecate directly into the toilet bowl. A specimen container would need to be placed in the commode. Usually 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient for a stool specimen.

A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding?

Have the client rest for half an hour and then reassess. If the stoma is prolapsed, the nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to it. Irrigation and manipulation are not recommended responses to this situation.

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?

Hyperactive bowel sounds Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.

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

A client with terminal cancer is taking high doses of a narcotic for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

Increase fiber in the diet. Narcotics decrease gastrointestinal motility, resulting in constipation. Bowel care strategies include increasing mobility, as well as fiber and fluid in the diet.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas. Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.

Which medication causes constipation?

Iron supplements 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.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

Left lateral The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?

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

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?

Lower the solution container and check the temperature and flow rate. If the client experiences severe cramping when the enema solution is introduced, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. A client should not be placed on a bedpan until after the rectal tube is removed. The rectal tube does not need to re-positioned or removed.

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply.

Place the client in a side-lying position. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. Provide a sitz bath or tub bath after the procedure to soothe the perianal area The nurse would have the client in a side-lying position. The nurse would use nonsterile gloves for the procedure because the intestinal tract is not sterile. The nurse would lubricate the index finger generously to reduce irritating the rectum, and insert the finger gently into the anal canal. The nurse would not have the client lie on the stomach. The nurse would use a gentle action, not a vigorous one, to break up the hardened mass of stool. The nurse would not use an enema unless it was ordered by the health care provider.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

Sims Sims position is appropriate as it promotes gravity distribution of the solution. Other choices are incorrect positions.

The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?

Skin turgor response of 6 seconds The nurse is required to report any abnormal findings to the health care provider. Skin turgor response that is greater than 3 seconds, especially in an older adult client, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. All other assessment findings are normal.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily. If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway. The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

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. Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 mL of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.

A nurse is preparing a client for colon surgery. Which teaching should the nurse provide first to prepare the client for what to expect after surgery?

The nurse will listen to the bowel sounds regularly. Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, which may cause a condition termed paralytic ileus. This temporary stoppage normally lasts 24 to 48 hours. Nurses will listen for bowel sounds as part of regular assessments. Fluids will be encouraged, but measuring fluid intake, not urinary output, will determine adequate fluid intake. The pulse will be measured to establish a baseline and observe for indicators of change. Assessing skin turgor can help to assess for dehydration.

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

A nurse is teaching a client how to change his ostomy appliance. Which instructions should be incorporated into the teaching plan?

Use toilet tissue to remove any excess stool from the stoma. Excess stool may be removed from the stoma using toilet paper. The pouch faceplate should be removed from the skin by pushing, rather than pulling, the skin from the appliance. If reusable, the appliance should be washed in lukewarm soap and water. Skin protectant should be applied to a 2-in (5 cm) radius around the stoma and allowed to air dry about 30 seconds.

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 and mild soap. 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.

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. 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.

Which factor is related to developmental changes in bowel habits for older adult clients?

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

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

Whole wheat spaghetti and broccoli To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.

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?

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

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 Opioids have a very high potential to cause constipation. Anticoagulants, hormone replacements, diuretics, and adrenergic blockers are not among the medications commonly implicated in cases of constipation.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to:

blue Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.

A student nurse studying human anatomy knows that a structure of the large intestine is the:

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

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 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.

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?

fecal occult blood test, barium studies, endoscopic examination There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

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?

hypertonic saline 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.

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 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.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

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

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 The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:

physiologic or lifestyle changes in the client. Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence.

The 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?

removes hardened fecal impactions from the rectum 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.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds 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.

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?

water and mild soap 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.