Bowel Elimination Flashcards
The nurse knows that most nutrients are absorbed in which portion of the digestive tract
Duodenum
Rationale: most nutrients are absorbed in the duodenum with the exception of certain vitamins, irons and salt (which absorb in ileum). Food is broken down in the stomach
The nurse would expect the least formed stool to be present in which portion of the digestive tract
Ascending
Rationale: the path of digestion starts at ascending then goes to transverse, descending and finally into sigmoid
Which of the following is not a function of the large intestine
Absorbing nutrients
Rationale: nutrient absorption is done in the small intestine. Absorbing water, secreting bicarbonate, and eliminating waste is in large intestine
The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because
Mastication triggers the digestive system to begin peristalsis
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend
Grape and walnut chicken salad sandwich on while wheat bread
Rationale: a healthy diet for the bowel should include foods high in bulk forming fiber. Whole gains, fresh fruit, and fresh vegetables are excellent sources.
A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of 5e laxative, the patent had difficulty with constipation and wonders if she needs tot are laxatives again. The nurse should educate the patient that
Long term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur
A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement
Raising the head of the bed
Rationale: lying in bed is an unnatural position, raising the head of the bed assist the patient into a more normal position that allows proper contraction of muscle for elimination
Which patient is most a risk for increased peristalsis
A 21 year old patient with three final examinations on the same day
Rationale: stress can stimulate digestion and increase peristalsis
A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate
“ do you take iron supplements “
Rationale: certain medications and supplements, such as iron, can alter the color of stool.
Which physiological change can cause a paralytic lieus
Surgery for crowns disease and anesthesia
Rationale: surgical manipulation of the bowel can cause a paralytic ileus also electrolyte imbalance, wound infection, and effects of medication
Fecal impactions occur in which portion of the colon
Rectum
Rationale: a fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled
The nurse provider knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient
A 70 year old patient with stool incontinence
Rationale: a bowel elimination program is helpful for a patient with incontinence, it helps them to defecate normally
Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation
Use the mobility device to place that patient on a bedside commode
Rationale: the best way for this is to assist the patient into a posture that is as normal as possible when defecating. Using a mobility device promotes nurse and patient safety.
The nurse is devising a plan of care for a patient with the nursing diagnosis of constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation
The patient reports eliminating a soft, formed stool
Rationale: the nurses goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed
The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately
Presence of blood in the stool
Rationale: blood in stool may indicate a problem with the surgical procedure, and the physician should be notified
The nurse would anticipate which diagnostic examination for a patient with black tarry stools
Upper endoscopy
Rationale: black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding
The nurse attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action
Donning gloves for digital removal of the stool
Rationale: when enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalances
The nurse should question which order
A kayexalate enema for a patient with hypokalemia
Rationale: kayexalate binds to hell 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 imbalance. Hypertonic solutions are intended for patients who cannot handle lard fluid volume and are contraindicated for dehydration patients.
The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by
Reporting any abnormal findings to the provider
Rationale: abnormal findings such as a positive test should be reported to the provider.
After a patient returns from a barium swallow, the nurses priority is to
Encourage the patient to increase fluids to flush out the barium. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk
While a cleansing enema is administered to an 80 year old patient, the patient expresses the urge to defecate. What is the next priority nursing action
Positioning the patient in the dorsal recumbent position with a bed pan
Rationale: patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in coral recumbent posting will allow the nurse to continue to administer the enema.
A nurse is educating a patient on how to irrigate am ostomy bag. Which statement by the patient indicated the need for further instruction
“ I can use a fleet enema to save money because it contains the same irrigation solution”
Rationale: enema applicators should never be used in the stoma because they can cause damage.
A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression
Salem sump
Rationale: the Salem sump has the width and functionality needed to both feed and suction, and its ideal for a bowel obstruction. Bowel obstruction causes a back up into the gastric area; a nasogastric tube may be inserted to decompress secretions and gasses from the GI tract
A patient had an illeostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy
Turkey meatloaf with white rice and apple juice
Rationale: the patient should consume easy to digest low fiber foods such as poultry, rice and noodles and strained fruit juices
A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is the most appropriate
Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying
Rationale:
The nurse knows that the ideal time to change an ostomy pouch is
Before eating a meal, when the patient is comfortable
The nurse administers a cathartic to a patient. The nurse determined that the cathartic has had
A bowel movement
Rationale: a cathartic is a laxative that stimulates a bowel movement
An older adults perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should
Apply a skin protective lotion after perineal care
Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube
Lubricating the nares with water soluble lubricant
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
“If I get a positive result, I have gastrointestinal bleeding”
Rationale: a positive result does not mean GI bleeding; it could be false positive from consuming red meat or raw vegetables.
A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury
Falls from attempts to reach the bathroom
Rationale: the nurse is most concerned about the WORST injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury the patient should clear the path and reinforce use of the call light
A nurse is performing assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding
Hypoactive bowel sounds
Rationale: no bowel movement indicates hypo motility of the GI tract. Assessment findings would indicate hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation(using hands)
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect
Decreased serum bicarbonate
Rationale: patients with chronic diarrhea are dehydrated with decrease blood pressure, loss of electrolytes, nutrients, fluids which decreases energy levels.
The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately
Stoma is purple
Rationale: a purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance.
A patient had constipation and hypernatremia( high concentration of sodium in blood). The nurse prepares to administer which type of enema
Tap water enema
Rationale: tap water would draw fluid into the system and would help flush out excess sodium.
A guaiac test has been ordered. The nurse knows that this is a test for
Blood that can not be seen
Rationale: fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the makes eye.
The nurse should place the patient in which position when preparing to administer an enema
Side lying sims position
The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse indicate
Bowel sounds
Rationale: the nurse does want to hear the presence of bowel sounds, absent bowel sounds may indicate complication from surgery
