Deck 37: Bowel Elimination

Question 1

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

Answer 1

Golden yellow and loose

Question 2

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

Answer 2

Hand hygiene and wearing gloves

Question 3

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?

A) 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.

Answer 3

The position does not facilitate downward pressure.

Question 4

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

Question 5

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

Question 6

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

Question 7

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?

A) Imbalanced Nutrition: Less than Body Requirements
B) Deficient Fluid Volume
C) Impaired Tissue Integrity
D) Impaired Urinary Elimination

Question 8

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

Question 9

A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby?

A) Yellow, loose, odorless
B) Brown, paste-like, some odor
C) Brown, formed, strong odor
D) Black, semiformed, no odor

Question 10

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

Question 11

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?

A) Decrease high-fiber foods
B) Decrease amount of fluids
C) Omit fruits if eating vegetables
D) Nothing; this is a good diet

Question 12

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."

Question 13

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."

Question 14

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

Question 15

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that 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

Question 16

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

Question 17

An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea?

A) Heart tones
B) Lung sounds
C) Skin turgor
D) Activity level

Question 18

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?

A) Routine urinalysis
B) Chest x-ray
C) Stool sample
D) Sputum sample

Question 19

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on:

A) 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.

Question 20

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.

Question 21

The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason?

A) Detect abdominal masses
B) Determine abdominal firmness
C) Assess softness of abdominal muscles
D) Assess degree of abdominal distention

Question 22

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) Assist client to 30- to 45-degree position, unless this is contraindicated.
B) 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.

Question 23

A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ...

A) Allergic to sugar
B) Lactose intolerant
C) Experiencing infectious diarrhea
D) Deficient in fiber

Question 24

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?

A) Increased bowel sounds
B) Abdominal tenderness
C) Areas of distention
D) Muscular resistance

Question 25

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.

Question 26

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.

Question 27

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

Question 28

A nurse is providing care to a client who has undergone a colonoscopy. Which of the following 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

Question 29

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document?

A) "Ileostomy bag half filled with liquid feces."
B) "Ileostomy bag half filled with hard, formed feces."
C) "Colostomy bag intact without feces."
D) "Colostomy bag filled with flatus and feces."

Question 30

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) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.
D) Instruct the client not to bear down while extracting feces to prevent vagal response.

Question 31

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 nursing diagnosis would the nurse most likely identify?

A) Constipation
B) Perceived constipation
C) Risk of constipation
D) Bowel incontinence

Question 32

A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions 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.

Question 33

A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client?

A) Oil retention enema
B) Carminative enema
C) Anthelmintic enema
D) Nutritive enema

Question 34

A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse 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.