A nurse is giving an enema to a client who doubles over in pain with severe cramping. What
intervention would be appropriate in this situation? Correct Ans-Lower the solution
container and check the temperature and flow rate.
Which actions are important goals of a bowel training program for clients with spinal cord
injuries? Select all that apply. Correct Ans-Maintain soft stool consistency.
Develop a routine method for stool evacuation.
Prevent fecal impaction
A client has received nursing teaching about proper skin care at a stomal site. The nurse's
teaching has been effective when the client identifies which solution is used to clean the
stoma? Correct Ans-water and mild soap
The nurse is preparing to administer a hypertonic saline enema. How much should the nurse
prepare to administer? Correct Ans-120 mL
, Bowel Elimination Test with Complete Solutions
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? Correct Ans-an increase in the client's blood pressure
A postoperative client is reporting abdominal distention and pressure related to intestinal gas.
The nurse performs a physical assessment. What percussion sound is consistent with excess
flatus trapped in the intestine? Correct Ans-Hyperresonance
The nurse is obtaining a health history from a client. The client states, "I have to take laxatives
every day or I don't have a bowel movement." What primary risk does the nurse need to
assess for among clients who use laxatives long term? Correct Ans-dependence
A nurse is administering a prescribed solution of cottonseed oil to a client during an enema.
What is the outcome of the use of cottonseed? Correct Ans-lubricates and softens stool
A nurse inserts a rectal suppository into a middle-age female client. The client says that she
has an urge to expel the suppository instantly. Which action should the nurse perform?
Correct Ans-Ask the client to contract the gluteal muscles
, Bowel Elimination Test with Complete Solutions
A nurse caring for an older adult client who reports flatulence suggests that the client
ambulate. The nurse also administers the prescribed antiflatulent medication. Follow up
reveals that the client has not obtained relief. The nurse anticipates that the physician will
most likely order which type of enema? Correct Ans-Return-flow enema
A nurse needs to administer a hypertonic enema solution to the client. Which actions must
the nurse perform? Select all that apply. Correct Ans-Help the client into a Sims' position.
Compress the container as the solution instills.
Encourage the client to retain the solution.
Which factors can affect bowel elimination? Select all that apply. Correct Ans-mobility
diet
fluid intake
medications
sensory impairments
A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage
more comfortable. Correct Ans-False
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