The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which foods would the nurse suggest as natural intestinal deodorizers?
Yogurt and buttermilk
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
For which one of the following patients would a hypertonic solution enema be contraindicated?
A patient with renal impairment
A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask?
-have you started a new medication?
-do you use laxatives?
-what are your normal bowel habits?
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
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
Stop the procedure, monitor heart rate and blood pressure
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. The nurse knows this is indicative of:
fecal impaction
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
(pallor = anemia; dark = ischemia)
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
(also contains large quantities of electrolytes)
When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of which of the following reasons?
physiologic or lifestyle changes in client
The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?
skin turgor response 6 seconds
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?
lubricates and softens stool
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which diet?
diet lacking in fruits and vegetables
Which factor is related to developmental changes in bowel habits for older adult clients?
weakened pelvic muscles lead to constipation
The nurse is administering magnesium sulfate to a patient with constipation. What mechanism of action would the nurse expect from this drug?
Drawing water into the intestines to stimulate peristalsis
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 places the client in Fowler's position
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
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
A student nurse studying human anatomy knows that a structure of the large intestine is the:
cecum
(colon and rectum)
During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:
auscultation
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
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
Which enema solution lubricates the stool and intestinal mucosa without distending the intestine?
oil
Which symptom is a known side effect of antibiotics?
diarrhea
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
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
(indicates presence of blood in stool sample)
When educating an older adult client on the prevention of constipation, the nurse should provide which educational intervention?
increase intake of fresh vegetables
True or False: A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable.
False
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 inches (7.5 to 10 cm) for an adult.
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.
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
The nurse is caring for a client with the NANDA-I nursing diagnosis of Perceived Constipation. Which assessment data does the nurse anticipate to collect?
-chronic purging
-reports using laxatives several times daily
(refers to a condition in which clients believe themselves to be constipated, but are not)
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
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
-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 nurse is teaching a client about foods with high fiber. Which food will the nurse recommend that the client consume?
brown rice
The nurse faculty is presenting a lecture on the gastrointestinal (GI) system. Which statements, if given by the nursing students, would indicate to the faculty that the lecture was effective?
-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 for too long
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?
Sims
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