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Bowel/Ostomy ISB
Nightingale BSN 205, Elimination ISB (Bowel/Ostomy Care)
| Question | Answer |
|---|---|
| The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? | Lubricate the first 6-8cm (2.5-3 inches) of the tip of the tube |
| Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient w/ dementia? | Perform hand hygiene before donning gloves. |
| Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? | Provide assistance to the bathroom for expulsion of fluid and stool. |
| The nurse is delegating to NAP the administration of an enema for older adult patient who is recovering from a stroke. The enema order reads, Enemas until clear. Which statement made by NAP requires follow-up? | It may take three or four enemas to achieve a clear return. |
| One of the defense mechanisms in place in the organs/tissues of the reproductive tract that prevent microbial infection includes | I'll instill the solution and then check in on my other patients until i get the call signal. |
| The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by NAP requires follow-up? | The patient could experience an acid-base imbalance. |
| A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select All) | The patient is an elderly woman. The patient takes opioids for chronic back pain. The patient takes daily iron and calcium supplements. |
| A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding? | The ascending colon would be found in the right side of the patient's abdomen. |
| An increase in venous pressure caused by liver disease can result in the development of: | Hemorrhoids |
| The comatose patient in the ICU who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse expect? | Impaction |
| The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? | A decrease in heart rate |
| An adult patient is scheduled for an abdominal CT scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: | 1000 mL or less of tap water |
| The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? | The nurse squeezes and released the bottle several times until all of the solution has entered the patient. |
| An adult patient complains of cramping during the administration of an enema. What could be a possible cause? (Select All) | The solution was instilled too rapidly. The enema solution was too cold |
| Which of the following is the best example of documentation of enema administration? | 0830 800mL of tap water enema administered. Return clear w/ no fecal material. Bowel sounds present in all 4 quadrants pre and post procedure`. Abdomen nondistended. Patient states "I'm glad that's over." |
| The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP would require correction? | The NAP inserts the tip of the rectal tube 5-7 inches after lubricating it. |
| A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? | Administer a third enema |
| An infant is to have an enema. Which solution would the nurse anticipate using? | Normal saline. |
| A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucous. What is your best response? | "The distal stoma may secrete mucus and that would be normal." |
| A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response? | "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?" |
| A patient is scheduled to have an ileostomy. The patient asks, "Will I always have to wear a pouch?" What is the nurse's best response? | "Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times." |
| The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect? | The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to 1/4 inch larger than the stoma. |
| When is the best time to change the skin barrier pouch? (Select All) | Several hours after breakfast. Several hours after lunch. |
| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select All) | Basin w/ warm tap water. Gauze pads or washcloth. Towel/disposable waterproof barrier. Pouch closure device. Clean gloves. Pouch: clear drainable colostomy/ileostomy in correct size for 2-piece system /1-piece type w/ attached skin barrier. |
| Identify interventions for irritation around the stoma. (Select all that apply.) | Make sure there is a good seal of the skin barrier/pouching system. Determine whether the patient's skin is reacting to adhesive removal. Consult the ostomy care nurse. Determine whether a different type of pouching system is needed to prevent leakage. |
| Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? | A lack of circulation to the stoma. |
| From the following, choose the four primary functions of the colon. (Select All) | Elimination. Absorption. Protection. Secretion. |
| From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared fleet enema. (Select All) | Clean disposable gloves. Toilet paper and/or basin w/ warm water, washcloth, towel. Waterproof bed pad. Commercially prepared enema product. Water-soluble lubricant. |
| The nurse listens for bowel sounds before administering an enema. The patient asks, "why are you listening to my abdomen?" The nurses accurate response is: | "To determine the presence of bowel sounds, which indicates the intestines are working." |
| To which of the following patients would it be considered acceptable to administer an enema w/out the nurse needed to question the order? | A patient who is going to have abdominal surgery. |
| A nurse is preparing to administer an enema. Which of the following indicates correct understanding? | The nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation. |
| The nurse is reviewing enema administration w/ NAP. Which of the following statements by the NAP indicates further instruction is necessary? | "The rectal tube of an enema should be inserted 5-7.5cm (2-3 inches into the rectum of an adolescent." |
| Which of the following would be considered a normal finding after the administration and evacuation of an enema? | Abdominal distention is absent. |
| The patient 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. |
| Which of the following is considered a sterile procedure and therefore requires sterile gloves? | None of the above. |
| The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficult with this change in body image? | The patient continues to rely on the nurse to change the ostomy pouch. |
| How often should an ostomy pouch be changed? | Every 3 to 7 days. |
| The nurse is pouching a new ostomy. The patient asks why the nurse always measures the size of the stoma, stating, "don't you remember how large to cut the opening?" Which would be an inaccurate response by the nurse and require correction? | "The stoma typically increases in size with the passage of time." |
| Which of the following would be inappropriate to delegate to the NAP? | Pouching a newly established ostomy. |
| The NAP tells the nurse 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 defense against C. Difficile." |
| The nurse instructs the patient that health care provider has ordered an enema. The patient states, "An enema! I'm not constipated." What are other possible reasons for the order? | To administer a medication. Preparation for surgery. Preparation for diagnostic procedure. |
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alishalynne93
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