Chapter 47: Bowel EliminationPotter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is teaching a health class about the
... [Show More] gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
a. Ileum
c. Stomach
d. Duodenum
ANS: D
OBJ: Discuss the role of gastrointestinal organs in digestion and elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
a. Sigmoid
b. Transverse
c. Ascending
d. Descending
ANS: C
OBJ: Explain the physiological aspects of normal defecation. TOP: Assessment MSC: Physiological Adaptation
3. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion?
b. Ascending, transverse, descending, sigmoid, rectum, and cecum
c. Cecum, sigmoid, ascending, transverse, descending, and rectum
d. Ascending, transverse, descending, rectum, sigmoid, and cecum
OBJ: Discuss the role of gastrointestinal organs in digestion and elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
4. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)?
a. Performing the first postoperative pouch change
b. Maintaining a nasogastric tube
c. Administering an enema
d. Digitally removing stool
ANS: C
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP lanningMSC:Management of Care
5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
a. Broccoli and cheese soup with potato bread
b. Turkey and mashed potatoes with brown gravy
c. Grape and walnut chicken salad sandwich on whole wheat bread
Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Health Promotion and Maintenance
6. A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.
b
. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis.
Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain
c. situations.
d Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the
. food, and no waste products are produced.
ANS: A
Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
7. A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema
b. Withholding narcotic pain medication
c. Administering laxatives to the patient
OBJ: Discuss psychological and physiological factors that influence the elimination process. TOP: Implementation MSC: Basic Care and Comfort
8. Which patient is most at risk for increased peristalsis?
A 5-year-old child who ignores the urge to defecate owing to embarrassment
b. A 21-year-old female with three final examinations on the same day
c. A 40-year-old female with major depressive disorder
d. An 80-year-old male in an assisted-living environment
ANS: B
OBJ escribe common physiological alterations in elimination. TOP: Assessment MSC: Psychosocial Integrity
9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate?
a. “This is probably a false negative; we should rerun the test.”
b. “You should schedule a colonoscopy as soon as possible.”
c. “Are you under a lot of stress?”
“Do you take iron supplements?”
ANS: D
Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention
TOP: Implementation MSC: Health Promotion and Maintenance
10. Which patient will the nurse assess most closely for an ileus?
a. A patient with a fecal impaction
b. A patient with chronic cathartic abuse
c. A patient with surgery for bowel disease and anesthesia
d. A patient with suppression of hydrochloric acid from medication
ANS: C
OBJ escribe common physiological alterations in elimination. TOP:AssessmentMSC:Management of Care
11. A patient has a fecal impaction. Which portion of the colon will the nurse assess?
a. Descending
Transverse
c. Ascending
d. Rectum
OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Basic Care and Comfort
12. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?
a. A 25-year-old patient with diarrhea
c. A 40-year-old patient with an ileostomy
d. A 70-year-old patient with stool incontinence
ANS: D
The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate
MSC: Basic Care and Comfort
13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?
Administer a soapsuds enema every 2 hours.
b. Use a mobility device to place the patient on a bedside commode.
c. Give the patient a pillow to brace against the abdomen while bearing down.
d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan.
ANS: B
OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort
14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation?
a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patient’s lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds in all four quadrants.
ANS: A
OBJ:List nursing diagnoses related to alterations in elimination. TOP:EvaluationMSC:Management of Care
15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
b. Presence of blood in the stool
c. Malodorous stool
d. Continuous output from the stoma
ANS: B
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:AssessmentMSC:Management of Care
16. The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
a. Ultrasound
b. Barium enema
c. Endoscopy
d. Anorectal manometry
ANS: C
Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization.
DIF:Apply (application)REF:11571158
OBJ escribe nursing implications for common diagnostic examinations of the gastrointestinal tract.TOP lanningMSC:Management of Care
17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the nextpriority nursing action?
Preparing the patient for a second tap water enema
b. Obtaining an order for digital removal of stool
c. Positioning the patient on the left side
d. Inserting a rectal tube
ANS: B
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP: Implementation MSC: Basic Care and Comfort
18. A nurse is checking orders. Which order should the nurse question?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema for a patient with fluid volume excess
c. A Kayexalate enema for a patient with severe hypokalemia
d. An oil retention enema for a patient with constipation
ANS: C
Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid
TOP:ImplementationMSC:Management of Care
19. The nurse is performing a fecal occult blood test. Which action should the nurse take?
a. Test the quality control section before testing the stool specimens.
b. Apply liberal amounts of stool to the guaiac paper.
c. Report a positive finding to the provider.
d. Don sterile disposable gloves.
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Implementation MSC: Reduction of Risk Potential
20. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination.
c. Obtaining an order for a pain medication before the test is performed.
d. Removing all of the patient’s metallic jewelry.
ANS: D
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Implementation MSC: Reduction of Risk Potential
21. A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one?
1. Obtain baseline vital signs.
2. Apply clean gloves and lubricate.
3. Insert index finger into the rectum.
4. Identify patient using two identifiers.
5. Place patient on left side in Sims’ position.
6. Massage around the feces and work down to remove.
a. 4, 1, 5, 2, 3, 6
b. 1, 4, 2, 5, 3, 6
c. 4, 1, 2, 5, 3, 6
d. 1, 4, 5, 2, 3, 6
DIF:Understand (comprehension)REF:1166
OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort
22. Before administering a cleansing enema to an 80yearold patient, the patient says “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?
Rolling the patient into right-lying Sims’ position
b. Positioning the patient in the dorsal recumbent position on a bedpan
c. Inserting a rectal plug to contain the enema solution after administering
d. Assisting the patient to the bedside commode and administering the enema
ANS: B
If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into rightlying
23. A nurse is providing care to a group of patients. Which patient will the nurse see first?
a. A child about to receive a normal saline enema
b. A teenager about to receive loperamide for diarrhea
c. An older patient with glaucoma about to receive an enema
d. A middle-aged patient with myocardial infarction about to receive docusate sodium
ANS: C
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:AssessmentMSC:Management of Care
a. Salem sump
b. Small bore
c. Levin
d. 8 Fr
ANS: A
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP lanningMSC:Management of Care
25. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy?
a. Eggs over easy, whole wheat toast, and orange juice with pulp
b. Chicken fried rice with fresh pineapple and iced tea
c. Turkey meatloaf with white rice and apple juice
d. Fish sticks with sweet corn and soda
ANS: C
OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation
26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate?
Changing the skin barrier portion of the ostomy pouch daily
b. Emptying the pouch if it is more than one-third to one-half full
c. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma
ANS: B
OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation
27. The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take?
a. Instill solution into pigtail slowly.
b. Check placement after instillation of solution.
c. Immediately aspirate after instilling fluid.
d. Prepare 60 mL of tap water into Asepto syringe.
ANS: C
OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation
28. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect?
a. Reports decreased diarrhea.
b. Experiences pain relief.
c. Has a bowel movement.
d. Passes flatulence.
ANS: C
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination.
TOP:EvaluationMSC harmacological and Parenteral Therapies
29. An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do?
a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
b. Tape an occlusive moisture barrier pad to the patient’s skin.
c. Apply a skin protective ointment after perineal care.
d. Massage the skin with light kneading pressure.
OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort
30. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours.
OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Basic Care and Comfort
31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education?
c. “If I eat red meat before my test, it could give me false results.”
d. “I should check with my doctor to stop taking aspirin before the test.”
ANS: A
A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid
b. Dobhoff
Miller-Abbott
d. Sengstaken-Blakemore
ANS: A
OBJ: Discuss nursing care measures required for patients with a bowel diversion.
TOP lanningMSC:Management of Care
33. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques
ANS: D
OBJ: Discuss psychological and physiological factors that influence the elimination process. TOP: Implementation MSC: Safety and Infection Control
34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?
b. Increased fluid intake
c. Soft tender abdomen
d. Jaundice in sclera
ANS: A
OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Physiological Adaptation
35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect?
Distended abdomen
b. Decreased skin turgor
c. Increased energy levels
d. Elevated blood pressure
ANS: B
OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Physiological Adaptation
36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.
OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP:AssessmentMSC:Management of Care
a. Prevent gaseous distention
d. Prevent lower bowel inflammation
ANS: C
OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP: Planning MSC: Basic Care and Comfort
38. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient’s stool?
a. Bright red blood
b. Dark black blood
d. Mucoid
ANS: C
OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Assessment MSC: Physiological Adaptation
39. A patient is receiving opioids for pain. Which bowel assessment is a priority?
Clostridium difficile
b. Constipation
c. Hemorrhoids
d. Diarrhea
OBJ: Assess a patient’s elimination pattern. TOP: Assessment
MSC harmacological and Parenteral Therapies
40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy?
a. Keep fiber low.
d. Chew food thoroughly.
ANS: C
Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8ounce glass of fluid when they empty their pouch. This helps patients to
MULTIPLE RESPONSE
1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.)
Help the patient to the toilet at the designated time.
d. Maintain normal exercise within the patient’s physical ability.
e. Apply pressure with hands over the abdomen, and strain while pushing.
f. Choose a time based on the patient’s pattern to initiate defecation-control measures.
ANS: A, B, D, F
DIF:Understand (comprehension)REF:1168
OBJ: List nursing interventions included in bowel training. TOP: Implementation MSC:Health Promotion and Maintenance
2. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.)
c. A warning sign is rectal bleeding.
d. A warning sign is a sense of incomplete evacuation.
e. Screening with a colonoscopy is every 5 years, starting at age 50.
f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50.
OBJ escribe common physiological alterations in elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance [Show Less]