NU120 Lab: Chapter 34 Bowel Elimination

The nurse is caring for a patient who has been on bed rest for several weeks. The

nurse notes that the patient is continually seeping liquid stool rectally. What action should

the nurse take?

a. Hold the patient's antibiotics

b. Put the patient on a bran diet

c. Perform a digital rectal examination

d. Increase the dosage of the patient's antibiotics

ANS: C

Continual seepage of diarrhea may occur with an impaction, and a digital rectal

examination can verify its presence. Diarrhea is often due to diet or antibiotic use, which

alters the normal flora in the gastrointestinal tract. However, a physician's order is

required to change these, and continual seepage of stool is more likely the result of

impaction; this should be ruled out first.

The patient is a 74-year-old man who has been in the hospital for 4 days

following an orthopedic surgical procedure. He is concerned because he has not moved

his bowels every day as he did before surgery, but every other day. What action should

the nurse take?

a. Tell the patient to put himself on over-the-counter laxatives

b. Tell the patient that daily bowel movements are not always necessary

c. Tell the patient that with increasing age, his bowel movements should increase in

frequency

d. Tell the patient that she will call to get a laxative to get him back on track

ANS: B

Reinforce with older adult patients that as long as the consistency of the stool remains

normal and bowel movements occur with regularity, there is no need to have a bowel

movement daily. Therefore, patients should not place themselves on laxatives to avoid

constipation.

The nurse assesses that a patient has a severe fecal impaction. Which action taken by the nurse addresses this problem?

a. Administer laxatives

b. Provide a high-fiber diet

c. Perform a digital removal

d. Administer an enema

ANS: C

Prevention is the key to fecal impaction. However, once it occurs, digital removal of stool

is the only alternative

Which of the following patient conditions requires the nurse to exercise additional

caution during the digital removal of feces?

a. Heart disease

b. Abdominal pain

c. Urinary infection

d. Diabetes mellitus

ANS: A

Because of the potential to stimulate the sacral branch of the vagus nerve, patients with a

history of dysrhythmia or heart disease have a greater risk for changes in heart rhythm.

Be sure to monitor the patient's pulse before and during the procedure. This procedure

may be contraindicated in cardiac patients; if in doubt, verify with the physician.

Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea,

vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency.

Abdominal pain by itself is not indicative of the need for extra caution. Symptoms of

fecal impaction include urinary frequency, not infection. There is no correlation between

the two.

When evaluating a health care team member's ability to digitally remove feces, the nurse determined that further teaching is required in which of the following situations?

a. Staff member provides perianal skin care.

b. Staff member continues the procedure if bleeding starts.

c. Staff member follows the procedure by offering the patient a bedpan.

d. Staff member discontinues the procedure in the presence of bradycardia.

ANS: B

If the patient experiences bleeding from the rectum, assess the anal and perianal regions

for the source of bleeding.

The nurse is preparing to administer an enema to a patient. Of the following

choices, choose the enema that is most likely to lead to circulatory overload.

a. Hypertonic solution enema

b. Soapsuds enema

c. Tap water enema

d. Harris Flush enema

ANS: C

Tap water (hypotonic) enema should not be repeated after first instillation because water

toxicity or circulatory overload can develop.

Hypertonic solution is useful for patients who cannot tolerate large volumes of fluid.

Only 120 to 180 mL (4 to 6 ounces) is usually effective (e.g., commercially prepared

Fleet enema). Soapsuds enema (SSE) is pure castile soap added to tap water or normal

saline, depending on the patient's condition and frequency of administration. Use only

castile pure soap. The recommended ratio of pure soap to solution is 5 mL (1 teaspoon) to

1000 mL (1 quart) warm water or saline. Add soap to enema bag after water is in place

to reduce excessive suds. Harris Flush enema is a return flow enema that helps to expel

intestinal gas. Fluid alternately flows into and out of the large intestine. This stimulates

peristalsis in the large intestine and assists in expelling gas.

Which type of enema usually is ordered for an infant?

a. Tap water

b. Hypertonic

c. Oil retention

d. Physiological normal saline

ANS: D

Physiological normal saline is safest. Infants and children can tolerate only this type

because of their predisposition to fluid imbalance. If solution is prepared at home, mix

500 mL (1 pt) of tap water with 1 teaspoon table salt.

Tap water (hypotonic) enemas should not be given to infants and children and should not

be repeated after the first instillation in adults because water toxicity or circulatory

overload can develop.

The patient is being prepped for surgery and has an order for "enemas until clear."

The nurse realizes that she will be giving a maximum of how many enemas?

a. One

b. Two

c. Three

d. Four

ANS: C

The nurse is preparing to administer an enema to an adult patient who has normal

sphincter control. For administration of the enema, the patient is placed in which

position?

a. Right side-lying position

b. Dorsal recumbent position

c. Sims' position

d. Prone position

The nurse has been directed to provide an enema for an elderly female patient

who has very poor rectal sphincter control. Which position is the most appropriate

position for this patient?

a. Sims' position

b. Dorsal recumbent position on the bedpan

c. Sitting on the toilet

d. Right lateral position

ANS: B

If patient has poor sphincter control, position the patient on the bedpan in comfortable

dorsal recumbent position. Patients with poor sphincter control cannot retain all of enema

solution.

Administering enema with patient sitting on toilet is unsafe because curved rectal tubing

can abrade rectal wall.

How far should the nurse insert the tube or nozzle of a prepared enema into an

adult patient?

a. 1 to 1½ inches

b. 2 to 3 inches

c. 3 to 4 inches

d. 4 to 5 inches

ANS: C

Insert nozzle of container gently into anal canal; adult: 7.5 to 10 cm (3 to 4 inches).

If administering to an infant, insert the tip of the tube 2.5 to 3.75 cm (1 to 1½ inches).

However, children and infants usually do not receive prepackaged hypertonic enemas

because hypertonic solutions cause rapid fluid shift. If administering to a child, insert the

tip of the tube 5 to 7.5 cm (2 to 3 inches). However, children and infants usually do not

receive prepackaged hypertonic enemas because hypertonic solutions cause rapid fluid

shift. Inserting tip of tube more than 4 inches is not appropriate at any age.

Which of the following is an appropriate procedure for the nurse to implement

while administering an enema?

a. Keeping the solution at room temperature

b. Positioning the patient on the right side

c. Raising the enema bag to 12 inches above the patient

d. Instructing the patient to release the enema solution as soon as possible

ANS: A

Add warmed solution to enema bag: warm tap water as it flows from faucet, place saline

container in basin of hot water before adding saline to enema bag, and check temperature

of solution by pouring small amount of solution over inner wrist.

During the enema instillation, the patient experiences cramping. What action

should the nurse take?

a. Discontinue the procedure

b. Increase the height of the solution

c. Slow the rate of the infusion

d. Have the patient roll into a supine position

ANS: C

If abdominal cramping or pain develops, decrease height of enema bag, slow rate of

instillation, and/or have patient take slow deep breaths in through nose and out through

mouth.

An enema is given in the Sims' position.

The patient having a nasogastric (NG) tube inserted is disoriented. What action

should the nurse take?

a. Halt the procedure

b. Request assistance with insertion

c. Administer a hypnotic medication

d. Continue the procedure as with any other patient

ANS: B

If patient is confused, disoriented, or unable to follow commands, obtain assistance from

another staff member to insert the tube.

Alert patient that procedure is to begin. This decreases patient anxiety and increases

patient cooperation.

What is an appropriate technique for measuring the length of the tube for NG

insertion?

a. Measure from the nose to the ear to the patient's navel

b. Measure from the nose to the middle of the sternum

c. Measure and mark a point 30 inches from the end

d. Mark 50-cm point on the tube, measure in the traditional way, and insert halfway

between the two spots

ANS: D

Hanson method: First, mark 50-cm point on tube, then do traditional measurement. Tu

An appropriate technique for the nurse to implement during NG tube insertion is

to:

a. Rotate the tube if resistance is felt

b. Advance the tube in between swallows

c. Start with the patient's head flexed

d. Check the tube placement by instilling air and auscultating over the stomach

ANS: A

If resistance is met, try to rotate the tube and see if it advances. If still resistant, withdraw

tube, allow patient to rest, relubricate tube, and insert into other naris.

Advance tube 2.5 to 5 cm (1 to 2 inches) with each swallow of water. If patient is not

allowed fluids, instruct to dry swallow or suck air through straw. Advance tube with each

swallow. Initially instruct patient to extend neck back against pillow; insert tube slowly

through naris with curved end pointing downward. Verify tube placement: Check agency

policy for preferred methods for checking tube placement.

An appropriate measure for the nurse to implement for the patient with a

nasogastric (NG) tube in place is to:

a. Tape the tube up and around the ear on the side of insertion

b. Secure the tubing to the bed by the patient's head

c. Mark the tube where it exits the nose

d. Change the tubing daily

ANS: C

Once placement is confirmed, a mark should be placed by making a red mark or

using tape on the tube to indicate where the tube exits the nose. The mark or tube length

is to be used as a guide to indicate whether displacement may have occurred.

A patient is admitted for constipation. When planning care for this patient, the nurse recognizes that which interventions would help control constipation? (Select all that apply.)

a. Increases in activity level

b. Elimination of laxative use.

c. Decreased dietary fiber

d. Increased fluids

e. Timely response to urge to move bowels

A, B, D ,E

Interventions are available for the control of constipation. Initially, changes in lifestyle

include increased dietary fiber, increased fluids, moderate exercise, and elimination of

laxative use.

The patient has increased his fluid and dietary fiber intake, and has started a

supervised exercise program. However, he is still having problems with constipation.

Which of the following would be an effective intervention? (Select all that apply.)

a. Metamucil

b. Milk of Magnesia

c. Dulcolax

d. Mineral oil

ANS: A, B, C

Use the following stepwise levels of interventions. Bulk-forming laxatives (e.g., psyllium

[Metamucil], methylcellulose [Citrucel]) are safe, add bulk to the fecal material, and are

used in combination with a saline laxative (e.g., magnesium hydroxide [milk of

magnesia]) or an osmotic laxative (e.g., lactulose [Chronulac]). The patient should

increase water intake to enhance the effectiveness of bulk-forming laxatives. If

constipation continues, stimulant laxatives (e.g., bisacodyl [Dulcolax], senna [Senokot])

usually provide relief. Avoid emollient laxatives, such as mineral oil, because they are

associated with lipoid aspiration pneumonia

The patient is receiving a soapsuds enema but is having a difficult time retaining

the fluid. What action should the nurse take? (Select all that apply.)

a. Give the enema slowly

b. Place the patient in the dorsal recumbent position on a bedpan

c. Give the enema with the patient on the toilet

d. Give the enema in the right lateral position

ANS: A, B

Give enema slowly to aid absorption. If patient is full of stool, retention is difficult. As

stool is evacuated, there is more room in colon for additional fluid. If patient has poor

sphincter control, position the patient on the bedpan in comfortable dorsal recumbent

position. Patients with poor sphincter control cannot retain all of enema solution.

The Levin tube and the Salem sump tube are the tubes used most commonly for

stomach decompression. Which of the following statements about these tubes is true?

(Select all that apply.)

a. Levin tubes have a blue port that functions as an air vent

b. Insertion of these tubes is done as a sterile procedure

c. The blue air vent should not be used for irrigation

d. The Salem sump"PIGTAIL" port that functions as an air vent

e. The Salem pump is preferred for stomach decompression

ANS: C, D, E

The Levin tube is a single-lumen tube with holes near the tip. You connect the tube to a

drainage bag or an intermittent suction device to drain stomach secretions. The Salem

sump tube has two lumina: one for removal of gastric contents and one to provide an air

vent, which prevents suctioning of gastric mucosa into eyelets at distal tip of tube. A blue

"pigtail" is the air vent that connects with the second lumen. Never clamp off the air

vent, connect to suction, or use for irrigation. NG tube insertion does not require

sterile technique. Clean technique is adequate.

What should the nurse do to verify nasogastric (NG) tube placement? (Select all

that apply.)

a. Ask the patient to speak

b. Inspect posterior pharynx

c. Aspirate back on the syringe

d. Measure the pH of the aspirate

e. Auscultate the lung fields

ANS: A, B, C, D

Verify tube placement: (Check agency policy for preferred methods for checking tube

placement.) Ask patient to talk. If patient is unable to talk, the NG tube may have passed

through vocal cords. Inspect posterior pharynx for presence of coiled tube. The tube is

pliable and will coil up behind the pharynx instead of advancing into the esophagus.

Aspirate gently back on syringe to obtain gastric contents, observing color. Gastric

contents are usually cloudy and green but sometimes are off-white, tan, bloody, or brown.

Aspiration of contents provides means to measure fluid pH and thus determine tube tip

placement in GI tract.

Infrequent bowel movements (less than every three days), difficulty in evacuating

feces, inability to defecate, and hard feces are signs of ________________.

constipation

The __________ system is an intrarectal catheter that has a retention cuff,

intraluminal balloon, three pilot balloons, anchor straps, and a port for sampling stool.

The purpose of this system is to divert feces away from wounds and provide access for

administering rectal medications and irrigations.

Act of Flow Bowel Management

A bedpan that is designed for patients with body or leg casts or patients restricted

from raising their hips (e.g., following total joint replacement) is known as a

_____________.

fracture pan

______ is defined by a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate.

Constipation

The inability to pass a hard collection of stool is known as ______________.

fecal impaction

An ___________ is the instillation of a solution into the rectum and sigmoid

colon to promote defecation by stimulating peristalsis.

enema