Chapter 38 Bowel Elimination 333-03 QUIZ 3 PDF

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Chapter 38: Bowel Elimination

Question 1 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? Correct response:



Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1426

Question 2 A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? Correct response:



hemorrhoids

Explanation:

Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles. Reference:

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Chapter 38: Bowel Elimination - Page 1419

Question 3 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? Correct response:



left side-lying

Explanation:

When administering a cleansing enema, the client is most often positioned in a left sidelying (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. Reference:

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Chapter 38: Bowel Elimination - Page 1440

Question 4 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? Correct response:



affects absorption of fat-soluble vitamins

Explanation:

Elderly clients who use mineral oil to prevent or relieve constipation need to be informed that prolonged use affects the absorption of fat-soluble vitamins such as A, D, E, and K. Bleeding and tissue trauma does not occur due to use of mineral oil for constipation but during the digital removal of faction. Use of mineral oil for constipation does not develop healthier bowel elimination patterns, but the use of bulk-forming products containing psyllium or polycarbophil does. Loss of elasticity in intestinal walls and slower motility is due to old age, not the use of mineral oil. Reference:

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Chapter 38: Bowel Elimination - Page 1435

Question 5

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



blue.

Explanation:

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

Question 6 When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: Correct response:



physiologic or lifestyle changes in the client.

Explanation: Reference:

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Chapter 38: Bowel Elimination - Page 1421

Question 7 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? Correct response:



Document the output; this is normal.

Explanation:

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. Reference:



Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.

Question 8

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? You Selected:



The graduate places the client in Fowler’s position.

Correct response:



The graduate places the client in Fowler’s position.

Explanation:

Placing the client in Fowler’s position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it. Reference:

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Chapter 38: Bowel Elimination - Page 1440

Question 9 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? Correct response:



fecal occult blood test, barium studies, endoscopic examination

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1432

Question 10 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? Correct response:



25%

Explanation:

According to the Rome III criteria, symptoms must be present for 12 nonconsecutive weeks in the last 12 months for 25% of bowel movements. Reference:



Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.

Question 11 The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? Correct response:



50-year-old client with a family history of polyps

Explanation:

The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect. Reference:

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Chapter 38: Bowel Elimination - Page 1428-1429

Question 12 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. Correct response:

  

“Have you started a new medication?” “What are your normal bowel habits?” “Do you use laxatives?”

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1421-1425

Question 13 The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? Correct response:



Sims

Explanation:

Sims position is appropriate for a client who will receive this type of enema, as it promotes gravity distribution of the solution. Other choices are incorrect positions. Reference:

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Chapter 38: Bowel Elimination - Page 1454

Question 14 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? Correct response:



"I will administer enemas until the enema return is without stool."

Explanation:

“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. Reference:

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Chapter 38: Bowel Elimination - Page 1438-1439

Question 15 The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? Correct response:



“This test detects heme, a type of iron compound in blood in the stool.”

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1429

Question 16 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? Correct response:



water and mild soap

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1471

Question 17 The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply. Correct response:

  

age 50 and older a positive family history a history of inflammatory bowel disease

Explanation:

The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals. Reference:

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Chapter 38: Bowel Elimination - Page 1428

Question 18 A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? Correct response:



Attempt to irrigate the NG tube with water or normal saline.

Explanation:

An NG tube that is not draining should normally be irrigated. Turning the suction off and on is less likely to be effective, and it may be unsafe to leave the suction turned off for half an hour. Digestive enzymes are not used on NG tubes that are used for suction. Removing the NG tube would be an action of last resort. Reference:

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Chapter 38: Bowel Elimination - Page 1465-1467

Question 19 A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include? Correct response:



Plans to eat a snack of fruit twice per day.

Explanation:

By snacking on fruits and vegetables, the client can increase fiber in the diet. The amount of fish, protein, and fat do not relate to increasing or absorbing fiber in the diet. Reference:

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Chapter 38: Bowel Elimination - Page 1422-1423

Question 20 A client asks, “Why do some foods, like corn, come out undigested in my feces?” Which is the nurse’s best response? Correct response:



Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1441

Question 1 Which medication causes constipation? Correct response:



Iron supplements

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1422

Question 3 An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? Correct response:



Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

Explanation:

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

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Chapter 38: Bowel Elimination - Page 1443

Question 4 A student nurse studying human anatomy knows that a structure of the large intestine is the:

Correct response:



cecum

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1419

Question 5 The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? Correct response:



Left lateral

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1430

Question 6 1m 38s

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? Correct response:



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

Explanation:

The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination. Reference:

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Chapter 38: Bowel Elimination - Page 1426

Question 7 When reviewing a client’s chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? Correct response:



The client returned from a foreign country 2 days ago.

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1422

Question 9 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? Correct response:



Yogurt and buttermilk

Explanation:

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

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Chapter 38: Bowel Elimination - Page 1449

Question 10

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? Correct response:



Stop the procedure, monitor heart rate and blood pressure.

Explanation:

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. Reference:

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Chapter 38: Bowel Elimination - Page 1439

Question 11 The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client? Correct response:



Keep the client’s bed in the lowest position.

Explanation:

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 co...