Chapter 38, Bowel Elimination
The nursing instructor informs a student nurse that a client she is caring for has a chronic
neurologic condition that 1. decreases the client’s peristalsis. What nursing diagnosis is the most
likely risk for this client?
A) Constipation
B)
Diarrhea
C)
Deficient fluid volume
D)
Excessive fluid volume
Ans A
:
Feedback:
2.
Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine.
Decreased peristalsis will result in constipation because the movement of the fecal mass will occur
at a slower rate and more fluid will be absorbed in the colon.
During defecation, the client experiences decreased cardiac output related to the Valsalva
maneuver. After the Valsalva maneuver, the nurse assesses the client’s vital signs and expects to
observe which of the following?
A)
An increase in the client’s blood pressure
B)
A decrease in the client’s blood pressure
C)
An increase in the client’s respiratory rate
D)
A decrease in the client’s respiratory rate
Ans A
:
Feedback:
3.
When an individual bears down to defecate, the increased pressures in the abdominal and thoracic
cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the
bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to
the heart; this act elevates the client’s blood pressure.
While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools.
What stool characteristics are expected in breast-fed infants?
A)
Golden yellow and loose
B)
Dark brown and firm
C)
Yellow-brown and pasty
D)
Green and mucusy
Ans: A
Feedback:
4.
Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and
usually have little odor. With formula or cow’s milk feedings, infants’ stools vary from yellow to
brown and are pasty in consistency.
Which type of stool would the nurse assess in a client with an illness that causes the stool to pass
through the large intestine quickly?
A)
Hard, formed
B)
Black, tarry
C)
Soft, watery
D)
Dry, odorous
Ans C
:
Feedback:
About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When absorption does not
occur properly, such as when the waste products pass through the large intestine rapidly, the stool
is soft and watery.
5.
A)
A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this
baby?
Yellow, loose, odorless
B)
Brown, paste-like, some odor
C)
Brown, formed, strong odor
D)
Black, semiformed, no odor
Ans: A
Feedback:
6.
Breast-fed babies have more frequent stools, and the stools are yellow to golden and loose, usually
with little odor. Breast-fed babies can normally have 2 to 10 stools per day.
A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would
the nurse tell the parents about this behavior?
A)
“When he does this, scold him and he will quit.”
B)
“I don’t understand why this child is losing control.”
C)
“This is normal when a child this age is hospitalized.”
D)
“I will have to call the doctor and report this behavior.”
Ans: C
Feedback:
Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet
7.
A)
trained often regress and experience soiling when hospitalized, and scolding or acting disgusted
only reinforces the behavior.
A client is having difficulty having a bowel movement on the bedpan. What is the physiologic
reason for this problem?
It is painful to sit on a bedpan.
B) The position does not facilitate downward pressure.
C) The position encourages the Valsalva maneuver.
D)
The cause is unknown and requires further study.
Ans B
:
Feedback:
Most people assume the squatting or slightly forward-sitting position with the thighs flexed to
defecate. These positions result in increased pressure on the abdomen and downward pressure on
the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult.
The following foods are a part of a client’s daily diet: high-fiber cereals, fruits, vegetables, 2,500
mL of fluids. What would the nurse tell the client to change?
8.
A)
Decrease high-fiber foods
B)
Decrease amount of fluids
C)
Omit fruits if eating vegetables
D)
Nothing; this is a good diet
Ans
D
:
Feedback:
A)
A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel
elimination. Intake of the foods described makes the feces more bulky, so they move through the
intestine more quickly. The stool is softer and the time to absorb toxins is decreased (toxins are
believed to have a role in the development of colon cancer).
A young woman comes to the emergency department with severe abdominal cramping and
frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to
confirm this diagnosis?
Routine urinalysis
B)
Chest x-ray
C)
Stool sample
D)
Sputum sample
9.
Ans C
:
Feedback:
Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal
10.
cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be
confirmed by a stool sample.
A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen
last in the sequence when conducting an abdominal assessment?
A)
It is the most painful assessment method
B)
It is the most embarrassing assessment method
C)
To allow time for the examiner’s hands to warm
D)
It disturbs normal peristalsis and bowel motility
Ans D
:
Feedback:
The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation.
Inspection and auscultation are performed before palpation because palpation may disturb normal
peristalsis and bowel motility.
11.
What are two essential techniques when collecting a stool specimen?
A)
Hand hygiene and wearing gloves
B)
Following policies and selecting containers
C)
Wearing goggles and an isolation gown
D) Using a no-touch method and toilet paper
Ans: A
Feedback:
Use of medical aseptic techniques when collecting a stool specimen is imperative. Hand hygiene,
before and after wearing rubber gloves, is essential.
12.
What is occult blood?
A)
Bright red visible blood
B)
Dark black visible blood
C)
Blood that contains mucus
D)
Blood that cannot be seen
Ans: D
Feedback:
Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross
examination. It can be detected with simple screening tests, such as a Hematest.
13.
A nurse is scheduling diagnostic studies for client. Which test would be performed first?
A)
Fecal occult blood test
B)
Barium study
C)
Endoscopic exam
D)
Upper gastrointestinal series
Ans: A
Feedback:
14.
A)
Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo
multiple studies. They should follow a logical sequence when more than one test is required for
accurate diagnosis; that is, fecal occult blood tests to detect gastrointestinal bleeding; barium
studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors,
strictures, or other lesions; and endoscopic examinations to visualize an abnormality, locate a
source of bleeding, and if necessary, provide biopsy tissue samples.
A client has had frequent watery stools (diarrhea) for an extended period of time. The client also
has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be
appropriate?
Imbalanced Nutrition: Less than Body Requirements
B) Deficient Fluid Volume
C)
Impaired Tissue Integrity
D)
Impaired Urinary Elimination
Ans: B
Feedback:
A)
Bowel elimination problems may also affect other areas of human functioning. For example,
excessive diarrhea causes loss of body fluid, with resulting decreased skin turgor and concentrated
urine. Deficient Fluid Volume is an appropriate nursing diagnosis based on the data.
An infant has had diarrhea for several days. What assessments will the nurse make to identify risks
from the diarrhea?
Heart tones
B)
Lung sounds
C)
Skin turgor
D)
Activity level
15.
Ans: C
Feedback:
When infants and children become ill, they lose most fluids from their extracellular compartment,
which quickly leads to dehydration. The nurse would assess skin turgor to identify this problem.
A)
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse’s
response is based on:
Habitual laxative use is the most common cause of chronic constipation.
B)
If laxatives are not effective, the client should begin to use enemas.
C)
A laxative that works by a different method should be used.
D)
Chronic constipation is nothing to be concerned about.
16.
Ans A
:
Feedback:
17.
Occasional use of laxatives is not harmful for most people, but they should not become dependent
on them. Although many people do take laxatives because they believe they are constipated, most
are unaware that habitual use of laxatives is the most common cause of chronic constipation.
A client who has been on a medication that caused diarrhea is now off the medication. What could
the nurse suggest to promote the return of normal flora?
A)
Stool-softening laxatives, such as Colace
B)
Increasing fluid intake to 3,000 mL/day
C)
Drinking fluids with a high sugar content
D)
Eating fermented products, such as yogurt
Ans: D
Feedback:
Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To
promote the return of normal flora, the nurse can recommend an intake of fermented dairy
products, such as buttermilk or yogurt.
18.
A client is on bedrest, and an enema has been ordered. In what position should the nurse position
the client?
A)
Fowler’s
B)
Sims’
C)
Prone
D) Sitting
Ans: B
Feedback:
19.
A reclining position on the left side (Sims’ position) is recommended. The head may be slightly
elevated, but Fowler’s position should be avoided because the solution will remain in the rectum
and expulsion will occur rapidly, resulting in minimal cleansing.
Which is an expected outcome for a client undergoing a bowel training program?
A)
Have a soft, formed stool at regular intervals without a laxative.
B)
Continue to use laxatives, but use one less irritating to the rectum.
C)
Use oil-retention enemas on a regular basis for elimination.
D)
Have a formed stool at least twice a day for two weeks.
Ans A
:
Feedback:
Clients who have chronic constipation and impaction, and those who are incontinent of stool, may
b
e
n
e
f
i
t
f
r
o
m
a
b
o
w
e
l
t
r
a
i
n
i
n
g
p
r
o
g
r
a
m
.
T
h
e
p
u
r
p
o
s
e
o
f
t
h
i
s program is to manipulate factors within
20.
the client’s control (such as exercise or fluid intake) to produce the elimination of a soft, formed
stool at regular intervals without a laxative.
A client tells the nurse, “I increased my fiber, but I am very constipated.” What further information
does the nurse need to tell the client?
A)
“Just give it a few more days and you should be fine.”
B)
“Well, that shouldn’t happen. Let me recommend a good laxative for you.”
C)
“When you increase fiber in your diet, you also need to increase liquids.”
D)
“I will tell the doctor you are having problems; maybe he can help.”
Ans: C
Feedback:
A combination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has been shown to
be as effective as medications in controlling constipation. Caution the client to avoid increasing
fiber intake without drinking enough fluids because this can lead to a bowel obstruction.
A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of
the following 21. would she document?
A) “Ileostomy bag half filled with liquid feces.”
B)
“Ileostomy bag half filled with hard, form ed feces.”
C)
“Colostomy bag intact without feces.”
D)
“Colostomy bag filled with flatus and feces.”
Ans: A
Feedback:
The client with an ileostomy (temporary or permanent) has an opening into the small intestine.
Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.
22. A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal,
healthy stoma?
A) Pallor
B)
Purple-blue
C)
Irritation and bleeding
D)
Dark red and moist
Ans: D
Feedback:
The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness
(possible anemia), purple- blue color (possible ischemia), or bleeding.
A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse
23. assesses no feces in the collection bag. What should the nurse do next?
A)
Notify the physician immediately.
B)
Ask another nurse to check her findings.
C)
Nothing; this is normal.
D)
Recheck the bag in two hours.
Ans: C
Feedback:
24.
Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after
surgery, usually within two to five days.
A nurse is providing discharge instructions for a client with a new colostomy. Which of the
following is a recommended guideline for long-term ostomy care?
A)
During the first six to eight weeks after surgery, eat foods high in fiber.
B)
Drink at least two quarts of fluids, preferably water, daily.
C)
Use enteric-coated or sustained-release medications if needed.
D)
Use a mild laxative if needed.
Ans B
:
Feedback:
During the first six to eight weeks after surgery, the nurse should encourage the client with an
ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells) as well as any other
foods that cause diarrhea or excessive flatus. By gradually adding new foods, the ostomy client can
progress to a normal diet. The nurse should urge clients to drink at least two quarts of fluids,
preferably water, daily. The use of liquid, chewable, or injectable forms rather than long- acting,
enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are
dangerous because they may cause severe fluid and electrolyte imbalance.
A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions
25. should the nurse perform to determine the presence of fecal impaction?
A)
Inserted a lubricated, gloved finger into the rectum.
B)
Obtain a sharp intestinal x-ray.
C)
Insert a lubricated rectal tube into the rectum.
D)
Administer an oil retention enema into the rectum.
Ans: A
Feedback:
The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of
fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with
defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in
the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil
retention enema are measures used to remove hardened stool, not assess it.
The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the
26. abdomen for which reason?
A)
Detect abdominal masses
B)
Determine abdominal firmness
C)
Assess softness of abdominal muscles
D)
Assess degree of abdominal distention
Ans: A
Feedback:
The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen
helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal
distention.
A nurse is providing care to a client who has undergone a colonoscopy. Which of the following
27. would be most appropriate for the nurse to do after the procedure?
A)
Avoid giving solid food
B)
Administer a laxative to the client
C)
Monitor for rectal bleeding
D)
Limit oral fluid intake
Ans: C
Feedback:
The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should
provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are
avoided and liquids are encouraged. Laxatives are also given before the procedure.
During a home visit, the nurse learns that the client ensures a daily bowel movement with the help
of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which
28. nursing diagnosis would the nurse most likely identify?
A)
Constipation
B)
Perceived constipation
C)
Risk of constipation
D)
Bowel incontinence
Ans: B
Feedback:
The most appropriate nursing diagnosis for the client is perceived constipation, because the client
has made a self- diagnosis of constipation and ensures a daily bowel movement through the abuse
of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal
frequency of defecation accompanied by a difficult or incomplete passage of stool (and/or passage
of excessively hard, dry stool). Risk of constipation can be diagnosed if a client exhibits factors
that predispose him or her for developing constipation. Bowel incontinence would be indicated if
the client was experiencing an involuntary passage of stool.
A young woman has just consumed a serving of ice cream pie and develops severe cramping and
29. diarrhea. The school nurse suspects the woman is …
A)
Allergic to sugar
B)
Lactose intolerant
C)
Experiencing infectious diarrhea
D)
Deficient in fiber
Ans: B
Feedback:
Many people have difficulty digesting lactose (the sugar contained in milk products). The
breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient
quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of
bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after
ingestion of milk products.
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing
30. enema. What condition would be an expected finding?
A)
Increased bowel sounds
B)
Abdominal tenderness
C)
Areas of distention
D)
Muscular resistance
Ans: A
Feedback:
The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.
A physician orders a retention enema for a client to destroy intestinal parasites. Which of the
31. following enemas would be indicated for this client?
A)
Oil retention enema
B)
Carminative enema
C)
Anthelmintic enema
D)
Nutritive enema
Ans C
:
Feedback:
32.
Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to
lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to
expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish
fluids and nutrition rectally.
A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of
the following is an appropriate step in this procedure?
A)
Position the client in supine position as dictated by client comfort and condition.
B)
Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus.
C)
D)
Gently work the finger around and into the hardened mass to break it up and then remove pieces of
it.
Instruct the client not to bear down while extracting feces to prevent vagal response.
Ans C
:
Feedback:
33.
For digital removal of stool: Position the client on the left side (Sims’ position), as dictated by
client comfort and condition. Generously lubricate index finger with water-soluble lubricant and
insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around
and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear
down, if possible, while extracting feces, which will ease in removal.
A nurse assessing a client with an ostomy appliance documents the condition “prolapse” in the
client chart and notifies the physician. Which of the following statements describes this condition?
A)
The peristomal skin is excoriated or irritated because the appliance is cut too large.
B)
The system has leaks or poor adhesion leading to noticeable odor.
C)
The bag continues to come loose and become inverted.
D)
The stoma is protruding into the bag and may become twisted.
Ans D
:
Feedback:
34.
During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30
minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma
stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
A nurse is following a physician’s order to irrigate the NG tube of a client. Which of the following
is a recommended guideline in this procedure?
A)
B)
Assist client to 30- to 45-degree position, unless this is contraindicated.
Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe.
C)
If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air
vent.
D)
If unable to irrigate the tube, reposition client and attempt irrigation again; inject 20 to 30 mL of
air and aspirate again.
Ans:
A
Feedback:
To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is
contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline
solution (or amount indicated in the order or policy) into syringe. If Salem sump or doublelumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue
air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10
to 20 mL of air and aspirate again.
Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the
correct order.
1. Cleanse entire perianal area and pat dry.
2. Apply skin protectant and allow it to dry.
3. Separate buttocks and apply the pouch to the anal area.
4. Attach the pouch to a urinary drainage bag.
5. Hang the drainage bag below the patient.
35.
A)
2, 3, 4, 5, 1
B)
3, 4, 5, 1, 2
C)
1, 2, 3, 4, 5
D)
5, 4, 3, 2, 1
Ans
:
C
Feedback:
A
nurse would not be able to determine if the entire intestinal tract is clear