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The nurse should administer a medicated enema rather than delegating the task to NAP. True
Enema administration to a patient in traction should not be delegated to NAP. False
Enemas are used to relieve constipation. True
An oil-retention enema works by infusing large amounts of fluid into the colon and increasing peristalsis. False
Tap water enemas are hypotonic and can cause circulatory overload. True
Commercially prepared enemas are usually hypertonic and draw fluids into the colon. True
A reduction in bowel sounds may indicate __________________ . constipation
The absence of bowel sounds could indicate __________________ . obstruction
The presence of __________________ may indicate a recurrent problem with constipation. hemorrhoids
Palpating the abdomen for pain and/or __________________ helps provide a baseline for determining enema effectiveness. distention
An order for enema administration is required from the health care provider in a hospital setting. True
To establish a baseline for assessment of the effectiveness of enema administration, the nurse should auscultate for bowel sounds and palpate the abdomen before enema administration. True
Soap suds enema Oil-retention enema Hypertonic enema Carminative enema Hypotonic enema Isotonic enema - 5mL (1 tsp) castile soap - cottonseed oil in solution - 120 to 180mL commercially prepared enema - magnesium, glycerin water - 750 to 1000 mL tap water (adult) - Normal saline
Adult Adolescent Child weighing 15 kg Child weighing 32 kg - 750 to 1000mL - 500 to 700mL - 75 to 150 mL - 160 to 320 mL
The patient record should be reviewed for the presence of glaucoma before proceeding with an enema. True
It is appropriate to administer an enema without assessing bowel sounds. False
Pain may be caused by constipation or diarrhea but could also indicate other pathologies. True
You should administer as many enemas as it takes to get clear fluid return when administering enemas until clear. False
The water for a tap water enema or soap suds enema should be warm. True
The enema container should be held at least 24 inches above the anus. False Correct height is 12 to 18 inches (30 to 45 cm).
The tubing should be cleared of air before the solution is instilled. True
The flow of solution can be slowed if the patient experiences cramping or a sudden urge to defecate. True
The castile soap for the soap suds enema should always be added before the water is placed in the bag. False
A patient is to have a soap suds enema. As you are administering the enema, the patient complains of abdominal cramping. What should you do first? Slow or temporarily stop the infusion.
You decide to slow the rate of the enema infusion. How can you accomplish this? By lowering the height of the enema bag
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 one quarter inch larger than the stoma.
When is the best time to change the skin barrier pouch? (Select all that apply). Several hours after breakfast. Several hours after lunch.
Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply). Basin with warm tap water Gauze pads or washcloth Towel or disposable waterproof barrier Pouch closure device, such as a clamp Clean disposable gloves Pouch: clear drainable colostoy/ileostomy in correct size for two piece system or a one piece type
Identify interventions for irritation around the stoma. Select all that apply - Make sure there is a good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided - Determine whether the patient's skin is reacting to adhensive removal. - Consult the ostomy care nurse - Determine whether a di
Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? A lack of circulation to the stoma
The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates further instruction is needed? "I should clean the peristomal skin with soap and warm water."
Created by: Brandi Sizemore
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