C HAPTER 30: P ROMOTING B OWEL
E LIMINATION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An ambulatory clinic patient telephones to report diarrhea and to ask for
advice on medication to manage it. The best response by the nurse is, “Do
not use antidiarrheal medication for longer than:
a. 24 hours without calling back for an appointment.”
b. 48 hours without calling back for an appointment.”
c. 72 hours without calling back for an appointment.”
d. 96 hours without calling back for an appointment.”
ANS: B
Antidiarrheal medication should not be continued for more than 48
hours without calling a primary care provider.
DIF: Cognitive Level: Comprehension REF: p. 579
OBJ: Clinical Practice #1 TOP: Promoting Regular
Bowel Elimination KEY: Nursing Process Step:
Implementation MSC: NC LEX: Physiological Integrit y:
Pharmacological Therapies
,2. There is an order to administer a cleansing enema to an adult patient
before bowel surgery. The nurse will fill the enema bag with how many
milliliters of fluid for this procedure?
a. 500 to 1000 mL
b. 300 to 500 mL
c. 200 to 300 mL
d. 50 to 150 m L
ANS: A
The volume of the cleansing enema depends on the age of the patient —
for adults, it is between 500 and 1000 mL.
DIF: Cognitive Level: Application REF: p. 580 OBJ:
Clinical Practice #5 TOP: Enemas KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
3. A patient who is badly constipated has just received an oil retention
enema. The nurse encourages this patient to try to hold the enema for at
least how long before trying to have a bowel movement?
a. 10 minutes
b. 15 minutes
c. 20 minutes
d. 40 minutes
ANS: C
The oil retention enema should be retained for 20 minutes.
, DIF: Cognitive Level: Comprehension REF: p. 580
OBJ: Clinical Practice #5 TOP: Retention Enemas
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Pharmacological Therapies
4. A nurse is preparing a cleansing enema for an adult patient who is
constipated and has not responded to laxative use. Bef ore giving the
enema, the nurse should:
a. cool the solution to 70° F.
b. warm the solution in the microwave.
c. keep the solution at room temperature.
d. warm the solution to 105° F.
ANS: D
Solution that is too cool cannot be retained, and solution that is too hot
may cause injury to rectal tissues; it is best to warm it to 105° F.
DIF: Cognitive Level: Application REF: p. 581 OBJ:
Clinical Practice #5 TOP: Cleansing Enemas KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
5. A patient 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
because:
a. repeated enemas may cause more flatus.
b. the patient may develop an irritated rectum.
c. repeated enemas may cause electrol yte imbalance.
E LIMINATION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An ambulatory clinic patient telephones to report diarrhea and to ask for
advice on medication to manage it. The best response by the nurse is, “Do
not use antidiarrheal medication for longer than:
a. 24 hours without calling back for an appointment.”
b. 48 hours without calling back for an appointment.”
c. 72 hours without calling back for an appointment.”
d. 96 hours without calling back for an appointment.”
ANS: B
Antidiarrheal medication should not be continued for more than 48
hours without calling a primary care provider.
DIF: Cognitive Level: Comprehension REF: p. 579
OBJ: Clinical Practice #1 TOP: Promoting Regular
Bowel Elimination KEY: Nursing Process Step:
Implementation MSC: NC LEX: Physiological Integrit y:
Pharmacological Therapies
,2. There is an order to administer a cleansing enema to an adult patient
before bowel surgery. The nurse will fill the enema bag with how many
milliliters of fluid for this procedure?
a. 500 to 1000 mL
b. 300 to 500 mL
c. 200 to 300 mL
d. 50 to 150 m L
ANS: A
The volume of the cleansing enema depends on the age of the patient —
for adults, it is between 500 and 1000 mL.
DIF: Cognitive Level: Application REF: p. 580 OBJ:
Clinical Practice #5 TOP: Enemas KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
3. A patient who is badly constipated has just received an oil retention
enema. The nurse encourages this patient to try to hold the enema for at
least how long before trying to have a bowel movement?
a. 10 minutes
b. 15 minutes
c. 20 minutes
d. 40 minutes
ANS: C
The oil retention enema should be retained for 20 minutes.
, DIF: Cognitive Level: Comprehension REF: p. 580
OBJ: Clinical Practice #5 TOP: Retention Enemas
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Pharmacological Therapies
4. A nurse is preparing a cleansing enema for an adult patient who is
constipated and has not responded to laxative use. Bef ore giving the
enema, the nurse should:
a. cool the solution to 70° F.
b. warm the solution in the microwave.
c. keep the solution at room temperature.
d. warm the solution to 105° F.
ANS: D
Solution that is too cool cannot be retained, and solution that is too hot
may cause injury to rectal tissues; it is best to warm it to 105° F.
DIF: Cognitive Level: Application REF: p. 581 OBJ:
Clinical Practice #5 TOP: Cleansing Enemas KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Basic Care and Comfort
5. A patient 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
because:
a. repeated enemas may cause more flatus.
b. the patient may develop an irritated rectum.
c. repeated enemas may cause electrol yte imbalance.
