43 notecards = 11 pages (4 cards per page)
A nurse has auscultated the abdomen in all four quadrants for 5
minutes and has not heard any bowel sounds. How would this be
“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.
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.
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.
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, nausea, 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.
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.
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:
When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.
The type of stool that will be expelled into the ostomy bag by a
client who has undergone surgery for an ileostomy will
Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.
The nurse is changing a patient’s ostomy appliance and observes that
the peristomal skin is excoriated. What would be the nurse’s priority
intervention in this situation?
Make sure that the appliance is not cut too large.
The nurse would make sure that the appliance is not cut too large. Skin that is exposed inside of the ostomy appliance will become excoriated from the acidity of the stool. The nurse would not need to clean the outside of the bag because the peristomal skin is around the stoma and not exposed to the outside of the bag. The nurse would not suspect ischemia if the stoma was the normal color of pinkish-red. Excoriated peristomal skin does not indicate ischemia. The nurse could possibly notify the primary care provider of the situation, but this is not the best answer.
An older adult woman who is incontinent of stool following a
cerebrovascular accident will have which nursing
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.
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
Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnip, fish, onions, and garlic are foods that produce odor
A nurse is caring for a client with primary constipation. Which
factor is responsible for primary constipation?
inadequate intake of liquid
Primary constipation results from lifestyle factors such as insufficient fluid intake, inadequate intake of fiber, inactivity, or ignoring the urge to defecate.
A nurse is administering a prescribed solution of cottonseed oil to a
client during an enema. What is the outcome of the use of
lubricates and softens stool
Cottonseed, olive oil, or mineral oil lubricates and softens the stool so that it can be expelled more easily during a retention enema. Tap water and normal saline solution distend the rectum and moisten the stool, whereas a soap and water solution not only distends the rectum and moistens the stool but also irritates the local tissue. A hypertonic saline solution irritates local tissue.
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 student nurse is caring for a client with a colostomy. When
changing the ostomy appliance, the nurse faculty would intervene if
which action by the student is observed?
Starts at the bottom of the appliance, holding abdominal skin taut gently removes the faceplate
When removing the appliance, the nurse should start at the top, not bottom, to prevent spillage of intestinal content. The disposal pad protects the work surface. Emptying the appliance before removal prevents spillage of fecal material. The skin should dry completely to provide good adherence of the appliance; protectant to a 2-inch radius provides protect to the skin and prevents breakdown.
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
When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position, though positioning has not been shown to appreciably alter the result of a cleansing enema.
When caring for a client with fecal incontinence, the nurse knows
that fecal incontinence is the result of which of the following
Physiologic or lifestyle changes in 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
Which statement accurately describes the act of
Centers in the medulla and the spinal cord govern the reflex to defecate.
Two centers govern the reflex to defecate, one in the medulla and a subsidiary one in the spinal cord. Defecation refers to the emptying of the large intestine. When parasympathetic stimulation occurs, the internal anal sphincter relaxes and the colon contracts. Rectal distention leads to an increase in intrarectal pressure, causing the muscles to stretch and thereby stimulating the defecation reflex
A student nurse studying human anatomy knows that a structure of the
large intestine is the:
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.
The nurse is inserting a rectal tube to administer a large-volume
enema. Which nursing action is performed correctly in this
Slowly and gently insert the enema tube 3 to 4 inches (7.5 to 10 cm) for an adult.
The nurse would slowly and gently insert the enema tube 3 to 4 inches 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 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
Whole wheat spaghetti and broccoli
To promote bowel elimination, 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.
A nurse is caring for a client who has a large, hardened mass of
stool interfering with defecation, making it impossible for the client
to pass feces voluntarily. How should the nurse document this
The client has fecal impaction because the large, hardened mass of stool is interfering with defecation. Iatrogenic constipation occurs as a consequence of other medical treatment. Secondary constipation is a consequence of a pathologic disorder. Fecal incontinence is the inability to control the elimination of stool
Which symptom is a known side effect of
A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.
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 or to assess for an obstruction or to give a laxative
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."
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?
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.
Which enema solution lubricates the stool and intestinal mucosa
without distending the intestine?
Mineral, olive, or cottonseed oil are used to lubricate the stool and intestinal mucosa without distending the intestine.
A nurse is caring for a client with constipation. The incidence of
constipation tends to be high among clients that follow which
a diet lacking in fruits and vegetables
The incidence of constipation tends to be high among clients whose dietary habits lack sufficient raw fruits and vegetables, whole grains, seeds, and nuts, all of which contain adequate fiber. Dietary fiber, which becomes undigested cellulose, is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. A diet lacking in glucose and water will cause dehydration first and then constipation, depending on other constituents of the diet. Diets consisting of whole grains, seeds, and nuts provide fiber, which helps in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.
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.
When reviewing a client’s chart, which data related to a client
experiencing diarrhea might suggest to the nurse a causative
The client returned from a foreign country two 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 fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.
For which one of the following patients would a hypertonic solution
enema be contraindicated?
A patient with renal impairment
Hypertonic solutions are contraindicated for patients with renal impairment or reduced renal clearance, because these patients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia.
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 is a positive diagnostic finding, indicating the presence of blood in the stool sample.
A 5-year-old client has a gastrointestinal infection. His mother
plans to send him to school tomorrow. The school nurse knows that
which nursing outcome is most important to include in the care plan of
The client will demonstrate good health practices to prevent spread of infection.
Children should not, but may, return to a school or daycare setting during the infectious phase of their illness. Hand washing is key to preventing the spread of infection.
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
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.
Which does not occur with the Valsalva maneuver?
contraction of the external sphincter
Contraction of the external sphincter is a voluntary reflex in response to the defecation reflex.
A client with constipation has been instructed to increase his fluid
intake. The client is unsure what type of fluid he should consume. The
nurse's best response is that the client should
increase his intake of:
Recommendations to promote regular defecation include a fluid intake of 2,000 to 3,000 mL. Water is recommended as the fluid of choice because fluids containing large amounts of caffeine and sugar may have a diuretic effect.
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
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
Antibiotics (such as sulfamethoxazole-trimethaprim), iron, and immobility can cause constipation.
A client admitted with cellulitis of the leg has been prescribed
amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy,
the client develops severe diarrhea, and the nurse notifies the
physician. The nurse would anticipate which course of action in
response to the client's diarrhea?
discontinuation of the amoxicillin and the administration of a different antibiotic
The use of antidiarrheal drugs is not recommended for diarrhea related to the administration of amoxicillin-clavulanate potassium because it will prolong the exposure of the intestinal mucosa to the irritating effects of the antibiotic and toxin. If the diarrhea is severe, the drug may need to be discontinued.
During data collection of a client with bowel elimination concerns,
which appropriate questions would the nurse ask? Select all that
• “Do you use anything to help move your bowels?”
A client informs a nurse that he has had difficulty defecating over
the past 6 months. He describes his stools as firm and pebble-like and
sometimes he must strain to relieve himself. In order to diagnose this
client with constipation using the Rome III criteria, what percentage
of stool must be affected?
25% According to the Rome III criteria, symptoms must be present for 12 nonconsecutive weeks in the last 12 months for 25% of bowel movements.
Occult blood testing has been ordered for a hospitalized client.
Which meal would be acceptable for a client receiving occult blood
macaroni and cheese, corn, lettuce salad, and vanilla pudding
Certain foods and medication should be avoided when occult blood testing is performed because they can cause a false-positive result. The ingestion of red meat, animal liver and kidneys, salmon, tuna, mackerel, and sardines should be avoided for 4 days prior to testing. Clients should also avoid tomatoes, cauliflower, horseradish, turnips, melon, bananas, and soybeans
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
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.
A hypertonic enema solution lubricates the stool and intestinal
mucosa, making stool passage more comfortable.
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
"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day.
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