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bowel elimination
Ben 206
| Question | Answer |
|---|---|
| A nurse is assisting a client in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend | grape and walnut chicken salad sandwhich on whole wheat bread. |
| A client scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware that no more than three enemas should be given bcuz? | ** Repeated enemas may cause electrolyte imbalance. |
| The nurse is caring for clients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present | Ascending |
| The nurse is teaching a health class about the GI. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients. | Duodenum. |
| From the following choose the correct equipment to bring to the bedside to administer the commercially prepared fleet enema. | Clean disposable gloves, Water soluble lubricant, Toilet paper and basin with warm water, washcloth, and towel, Commercially prepared enema product, Waterproof bed pan |
| A nurse is preparing to administer an enema. Which of the following actions indicates correct understanding”? | the nurse hold the tubing in the clients rectum constantly until the end of fluid instillation |
| A nurse is reinforcing education with a client who will begin a bowel training program. An intervention this program does not include is: | use of an enema |
| A nurse is caring for a patient who bowel surgery 3 days ago and is now beginning to have a well functioning ostomy. The ostomy drainage bag should be emptied whenever it is: | 1/2 full |
| From the following choose the four primary functions of the colon | Absorption, Protection, Elimination, Secretion |
| The nurse is caring for a client who had a colostomy placed yesterday. The nurse should report which assessment findings immediately? | Stoma is purple. |
| The nurse listens for bowel sounds before administering an edema. The client asks why aer you listening to my abdomen? The nurse responds. | to determine the presence of bowel sounds, which may indicate that the intestines are working. |
| A nurse is preparing a cleaning enema for an adult client who is constipated and has not responded to laxative use. Before giving the enema the nurse should? | Warm the solution to 105 F |
| A nurse is caring for an immobile client who has abdominal pain and frequent small liquid stools. The client vomited his breakfast and is still nauseous Which action by the nurse is the highest priority?? | Check the client for a fecal impaction |
| A client is recovering from a hip fracture and is having difficulty defecating into a bedpan while lying in bed/ Which action by the nurse will assist the client in having a successful bowel movement. | Raising the head of the bed |
| The nurse is emptying an ileostomy pouch for a client. Which assessment finding will the nurses report immediately. | presence of blood in the stool |
| The nurse is caring for an anxious client who is scheduled for surgery for colostomy placement. While the nurse is talking to the client, the client states I am so scared the nurses most supportive response would be: | **What about your colostomy scares you? |
| A client is receiving opioids for pain. Which bowel assessment is a priority | Constipation |
| The client asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that | ** a colostomy Is an opening into the colon, whereas an ileostomy is an opening to ileum |
| The client is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse? | Lower the height of the enema container or clamp the tubing |
| The UAP tells the nurse that she doesn’t want to care for a certain patient because she is afraid of contracting C difficile. Which is the best response by the nurse? | good hand hygiene with soap and water is your best deffense |
| Which of the following would be considerd a normal finding after the administration and evacuation of an enema? | abdominal distension is almost absent |
| The nurse is pouching a new ostomy. The client asks why she always measures the size of the stoma starting. Don’t you remember how large to cut the opening? Which of the following would be an innacurate response by the nurse and would require correction | * the stoma typically increases in size with the passage of time |
| The nurse understands the important role in helping the client with an ostomy accept their change in self image. Which of the following indicates the client is having difficulty with this change in their body image. | ** The client continues to rely on the nurse to change the ostomy pouch |
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lcamarena7792