Treas/Wilkinson
Basic Nursing
ETB
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Chapter 29. Bowel Elimination
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry
stool. What should the nurse do?
1)
Notify the provider immediately.
2)
Do nothing; this is normal.
3)
Give the baby sterile water until the mother’s milk comes in.
4)
Apply a skin barrier cream to the buttocks to prevent irritation.
ANS:
2
The nurse should do nothing; this is normal. During the first few days of life, a term newborn
passes green-black, tarry stools known as meconium. Stools transition to a yellow-green color over
the next few days. After that, the appearance of stools depends upon the feedings the newborn
receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating
to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to
cleanse it. However, meconium leads to skin breakdown like a watery stool does.
PTS: 1
DIF: Moderate
REF: p. 968
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
____
2. Considering normal developmental and physical maturation in children, for which age would a
goal of “Achieves bowel control by the end of this month” be most realistic?
1)
18 months
2)
3 years
3)
4 years
4)
5 years
ANS:
2
Between ages 2 and 3 years, a child can typically control defecation, thereby making toilet training
possible. Nevertheless, some children, especially boys, may not achieve consistent bowel control
until somewhat later.
PTS:
1
DIF:
Moderate
REF: pp. 968-969
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Basic Nursing
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KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
____
3. The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which
behavior by the patient would be evidence of learning? The patient:
1)
Reduces her intake of gluten-containing products.
2)
Does not consume foods that contain lactose.
3)
Consumes only two servings of caffeinated beverages per day.
4)
Takes measures to reduce her stress level.
ANS:
4
Stress is a primary factor in the development of irritable bowel syndrome. Other risk factors
include caffeine consumption and lactose intolerance; however, they are not primary risk factors.
Celiac disease is associated with gluten intake.
PTS: 1
DIF: Moderate
REF: p. 969
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
____
4. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation?
The patient increases the intake of:
1)
Milk and cheese.
2)
Bread and pasta.
3)
Fruits and vegetables.
4)
Lean meats.
ANS:
3
The nurse should encourage the patient to increase his intake of foods rich in fiber because they
promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread,
pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.
PTS: 1
DIF: Moderate
REF: p. 978
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
Treas/Wilkinson
Basic Nursing
ETB
____
5. A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should
encourage the intake of which food to promote healing?
1)
Yogurt
2)
Pasta
3)
Oatmeal
4)
Broccoli
ANS:
1
29-3
Although the patient may have diarrhea, the goal is not to stop the diarrhea, but to eliminate the
pathogens from the digestive tract. The active bacteria in yogurt stimulate peristalsis and promote
healing of intestinal infections. Pasta is a low-fiber food that slows peristalsis. It does not promote
healing of intestinal infections. Oatmeal stimulates peristalsis, but it does not promote healing of
intestinal infections. Broccoli stimulates gas production; it is ineffective against intestinal
infections.
PTS: 1
DIF: Moderate
REF: p. 969
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____
6. A nurse is teaching wellness to a women’s group. The nurse should explain the importance of
consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce
servings)?
1)
3 to 4 servings a day
2)
5 to 6 servings a day
3)
7 to 8 servings a day
4)
9 to 10 servings a day
ANS:
3
A minimum of 7 to 8 servings of fluid should be consumed each day to promote healthy bowel
function.
PTS: 1
DIF: Easy
REF: p. 969
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall
Treas/Wilkinson
Basic Nursing
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____
7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours.
The patient complains that the last time he took this medication, he had frequent episodes of loose
stools. Which recommendation should the nurse make to the patient?
1)
Stop taking the drug immediately if diarrhea develops.
2)
Take an antidiarrheal agent, such as diphenoxylate.
3)
Consume yogurt daily while taking the antibiotic.
4)
Increase your intake of fiber until the diarrhea stops.
ANS:
3
Antibiotics such as cephalexin, given to combat infection, decrease the normal flora in the colon
that cause diarrhea. Bacterial populations can be maintained by encouraging the patient to
consume yogurt daily while taking the drugs. Diarrhea is a common adverse effect of antibiotics;
stopping the drug is not necessary. The patient should not be encouraged to take an antidiarrheal
agent at this time. Increasing the intake of fiber combats constipation, not diarrhea.
PTS: 1
DIF: Moderate
REF: p. 969
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____
8. Which collaborative interventions will help prevent paralytic ileus in a patient who underwent
right hemicolectomy for colon cancer?
1)
Administer morphine 4 mg IV every 2 hours for pain.
2)
Administer IV fluids at 125 mL/hr.
3)
Insert an indwelling urinary catheter to monitor I&O.
4)
Keep the patient NPO until bowel sounds return.
ANS:
4
Patients who require bowel surgery typically remain NPO until peristalsis returns, helping to
prevent paralytic ileus, a complication that can occur after the bowel is surgically manipulated.
Administering morphine promotes comfort but may increase the risk of ileus. Administering IV
fluids prevents dehydration but does not directly prevent ileus. Inserting an indwelling urinary
catheter prevents urine retention and facilitates monitoring postoperative urine output.
PTS: 1
DIF: Moderate
REF: p. 969; not stated directly in text
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Treas/Wilkinson
Basic Nursing
ETB
____
9. The nurse in a long-term care facility is teaching a group of residents about increasing dietary
fiber. Which foods should she explain are high in fiber?
1)
White bread, pasta, and white rice
2)
Oranges, raisins, and strawberries
3)
Whole milk, eggs, and bacon
4)
Peaches, orange juice, and bananas
ANS:
2
29-5
Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are
carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and
bananas are sources of potassium.
PTS: 1
DIF: Moderate
REF: p. 969
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension
____
ANS:
10. The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the
patient’s abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this
finding?
1)
Hyperactive bowel sounds
2)
Abdominal bruit sounds
3)
Normal bowel sounds
4)
Hypoactive bowel sounds
4
Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit is a hollow,
blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched
with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very
high pitched and more frequent than normal bowel sounds.
PTS: 1
DIF: Difficult
REF: p. 972
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Treas/Wilkinson
Basic Nursing
ETB
____
ANS:
29-6
11. The healthcare team suspects that a patient has an intestinal infection. Which action should the
nurse take to help confirm the diagnosis?
1)
Prepare the patient for an abdominal flat plate.
2)
Collect a stool specimen that contains 20 to 30 mL of liquid stool.
3)
Administer a laxative to prepare the patient for a colonoscopy.
4)
Test the patient’s stool using a fecal occult test.
2
To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that
contains 20 to 30 mL of liquid stool. An abdominal flat plate and a fecal occult blood test cannot
confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.
PTS: 1
DIF: Moderate
REF: pp. 974-975
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____
ANS:
12. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse
can conclude that learning occurs if the patient says, “For 3 days prior to testing, I should avoid
eating:
1)
Beef.”
2)
Milk.”
3)
Eggs.”
4)
Oatmeal.”
1
The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw
fruits and vegetables for 3 days prior to fecal occult blood testing.
PTS: 1
DIF: Moderate
REF: pp. 989-990
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
____
13. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse
should explain that ingestion of which substance may cause a false-negative fecal occult blood
test?
1)
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Basic Nursing
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Vitamin D
2)
Iron
3)
Vitamin C
4)
Thiamine
ANS:
3
Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of vitamin D,
iron, and thiamine does not. Iron can lead to a false-positive result.
PTS: 1
DIF: Moderate
REF: pp. 989-990
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension
____
ANS:
14. Which action should the nurse take to assess a 2-year-old child for pinworms?
1)
Press clear cellophane tape against the anal opening at night to obtain a specimen.
2)
Collect a freshly passed stool from a diaper using a wooden specimen blade.
3)
Place a smear of stool on a slide and add two drops of reagent.
4)
Prepare the patient for a flat plate (x-ray) of the abdomen.
1
To assess for pinworms, the nurse should press cellophane tape against the child’s anal opening
during the night or as soon as he awakens. Remove the tape immediately, and place it on a slide.
Perineal swabs may also be necessary for microscopic study. Collecting a fresh stool specimen
from a diaper describes the method for an infant or toddler. Placing a smear of stool on a slide and
adding a reagent describes fecal occult blood testing. An abdominal flat plate is not a method of
assessing for pinworms.
PTS: 1
DIF: Moderate
REF: p. 975
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
____
15. The nurse must irrigate the colostomy of a patient who is unable to move independently. How
should the nurse position the patient for this procedure?
1)
Semi-Fowler’s position
2)
Left side-lying position
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Basic Nursing
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3)
Supine with the head of the bed lowered flat
4)
Supine with the head of bed raised to 30 degrees
ANS:
2
The nurse should position an immobile patient in a left side-lying position to irrigate his
colostomy. Semi-Fowler’s, supine with the bed lowered flat, and the supine position with the head
of bed elevated to 30° are not appropriate positions for colostomy irrigation.
PTS: 1
DIF: Moderate
REF: p. 1008
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
____
ANS:
16. A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill
with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned.
Which recommendation should the nurse make to this mother?
1)
Consume a diet consisting of bananas, white rice, applesauce, and toast.
2)
Drink large quantities of water regularly to prevent dehydration.
3)
Take loperamide (an antidiarrheal) as needed to control diarrhea.
4)
Increase the consumption of raw fruits and vegetables.
1
The nurse should encourage the patient with diarrhea who has an appetite to consume a diet that
consists of bananas, white rice, applesauce, and toast. These foods are easy to digest, provide
calories for energy, and help provide a source of calcium. The patient should sip liquids frequently
to prevent dehydration; large quantities might worsen diarrhea. Medication, such as loperamide
(Imodium), is usually reserved for chronic diarrhea. Raw fruits and vegetables may worsen
diarrhea.
PTS: 1
DIF: Moderate
REF: p. 978
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____
17. Which is a key treatment intervention for the patient admitted with diverticulitis?
1)
Antacid
2)
Antidiarrheal agent
3)
Treas/Wilkinson
Basic Nursing
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Antibiotic therapy
4)
NSAIDs
ANS:
3
A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if antibiotic
therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are
not indicated for treatment of diverticulitis.
PTS: 1
DIF: Moderate
REF: p. 970
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
____
ANS:
18. The nurse assesses a patient’s abdomen 4 days after abdominal surgery and notes that bowel
sounds are absent. This finding most likely suggest which postoperative complication?
1)
Paralytic ileus
2)
Small bowel obstruction
3)
Diarrhea
4)
Constipation
1
Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication
associated with abdominal surgery. A small bowel obstruction and diarrhea produce hyperactive
bowel sounds. Constipation might be associated with hypoactive bowel sounds.
PTS: 1
DIF: Moderate
REF: p. 972
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
____
19. A patient with a colostomy complains to the nurse, “I am noticing really bad odors coming from
my pouch.” To help control odor, which foods should the nurse advise him to consume?
1)
White rice and toast
2)
Tomatoes and dried fruit
3)
Asparagus and melons
4)
Yogurt and parsley
Treas/Wilkinson
Basic Nursing
ETB
ANS:
29-10
4
Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also
bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to
cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a
patient with an ostomy.
PTS: 1
DIF: Moderate
REF: p. 987
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
____
ANS:
20. A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following
interventions is contraindicated?
1)
Apply an indwelling fecal drainage device.
2)
Apply an external fecal collection device.
3)
Place an incontinence garment on the patient.
4)
Place a waterproof pad under the patient’s buttocks.
1
An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive
days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or
injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for
patients who are ambulatory, agitated, or active in bed because the device may be dislodged,
causing skin breakdown. External devices cannot be used effectively when the patient has
Impaired Skin Integrity because they will not seal tightly. Absorbent products are not
contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent
products or an external collection device, the nurse should place a waterproof pad under the patient
to protect the bed linens.
PTS: 1
DIF: Difficult
REF: p. 1001
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
____
21. A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel
evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, nurse should
teach the patient to:
1)
Call the primary care provider if the stoma becomes pale, dusky, or black.
2)
Limit the intake of gas-forming foods such as cabbage, onions, and fish.
3)
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Irrigate the stoma to produce a bowel movement on a schedule.
4)
Avoid returning to the use of an ostomy appliance if he becomes ill.
ANS:
3
Patients with an ostomy in the descending or sigmoid colon may use colostomy irrigation as a
means to control and schedule bowel evacuation and possibly eliminate the need to wear an
ostomy pouch. Limiting the intake of gas-forming foods is a good idea from a social perspective;
however, it does not help achieve the goal of having regular bowel movements and thus,
eliminating the need to wear a pouch. When illness occurs, it may be difficult to control the output,
so the patient can use an ostomy appliance. This will not make it more difficult to schedule the
bowel movements after the illness passes.
PTS: 1
DIF: Moderate
REF: p. 971
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____
1. Which factor(s) place(s) the patient at risk for constipation? Choose all that apply.
1)
Sedentary lifestyle
2)
High-dose calcium therapy
3)
Lactose intolerance
4)
Consuming spicy foods
ANS: 1, 2
Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a sedentary
lifestyle commonly experience constipation. High-dose calcium therapy also predisposes a patient
to constipation. Lactose intolerance and consuming spicy foods are associated with a nursing
diagnosis of Diarrhea, not Constipation.
PTS: 1
DIF: Moderate
REF: p. 969
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Comprehension
____
2. A patient who has been immobile since sustaining injuries in a motor vehicle accident complains
of constipation. The nurse encourages him to consume eight to ten 8-ounce servings of fluid daily.
Which fluid(s) should the patient avoid because of the diuretic effect? Choose all that apply.
1)
Cranberry juice
Treas/Wilkinson
Basic Nursing
ETB
29-12
2)
Water
3)
Coffee
4)
Ginger ale
5)
Tea
ANS: 3, 5
Coffee, tea, and caffeine-containing sodas should be avoided because caffeine promotes diuresis,
placing the patient at further risk for constipation. Water is the preferred fluid; however, fruit juices
and decaffeinated sodas are also acceptable.
PTS: 1
DIF: Moderate
REF: p. 977
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension
____
3. The nurse must administer an enema to an adult patient with constipation. Which of the following
would be a safe and effective distance for the nurse to insert the tubing into the patient’s rectum?
Choose all that apply.
1)
2 in (5.1 cm)
2)
3 in (7.6 cm)
3)
4 in (10.2 cm)
4)
5 in (12.7 cm)
ANS: 2, 3
When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the
patient’s rectum. Two inches would not be effective because it would not place the fluid high
enough in the rectum. Five inches is too much.
PTS: 1
DIF: Moderate
REF: p. 994
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
Completion
1. When performing an abdominal assessment, what sequence of assessment techniques should the
nurse use? Label the steps from A to D, with A being the first step to perform.
A. Auscultation
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Basic Nursing
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29-13
B. Palpation
C. Percussion
D. Inspection
ANS:D, A, C, B
When performing an abdominal assessment, the nurse should follow the sequence: inspection,
auscultation, percussion, and palpation. Percussion and palpation may stimulate peristalsis, so the
techniques with the least contact should be done first.
PTS: 1
DIF: Moderate
REF: p. 972
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
2. The nurse is collecting a stool specimen. Arrange the following steps in the order in which the
nurse should perform them. Label the steps from A to D, with A being the first step to perform.
A. Have the patient defecate into a special container placed under the toilet seat.
B. Put on gloves and place the specimen in a specimen container.
C. Ask the patient to void to empty the bladder.
D. Place a label on the specimen container.
ANS:C, A, B, D
The nurse should ask the patient to void and then have him defecate into a special container placed
under the toilet seat. Next, the nurse should put on gloves and, using a tongue blade, place the
specimen into the container. Finally, she should label the specimen and send it to the laboratory for
analysis.
PTS: 1
DIF: Difficult
REF: pp. 989-990
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
3. When administering an enema, list the following steps in the order in which they should be
performed. Label the steps from A to F, with A being the first step to perform.
A. Document the results of the procedure.
B. Assess the patient for cramping.
C. Insert the tubing about 3 to 4 inches into the rectum.
D. Lubricate the tip of the enema tubing generously.
E. Raise the container to the correct height and instill the solution at a slow rate.
F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.
ANS:D, C, E, B, F, A
You must lubricate the tip before inserting the tubing. You would then insert the tubing and begin
instilling the solution before assessing for cramping that the instillation might produce. Only after
the solution is instilled would you ask the patient to hold the solution. The last action is to
document the results of the procedure, after the procedure is finished.
Treas/Wilkinson
Basic Nursing
ETB
PTS: 1
DIF: Difficult
REF: pp. 993-995
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
29-14