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NCO
week 12
| Question | Answer |
|---|---|
| The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? | Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. |
| Which would RN take to reduce risk of infection among patients, staff when administering an enema to 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. |
| nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, Enemas until clear. Which statement made by NAP requires the nurse to follow-up? | "It may take three or four enemas to achieve a clear return." |
| The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? | "I'll instill the solution and then check in on my other patients until I get the call signal." |
| An adult patient is scheduled for an abdominal computed tomography (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 releases 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 that apply.) | - 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 800 mL tap water enema administered. Return clear with 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 to 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 mucus. 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." |
| If a patient had to have part of the colon (large intestine) removed, which of the following may result? | 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 that apply.) | A. The patient is an elderly woman. C. The patient takes opioids for chronic back pain. E. 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 intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? | 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. |
| 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.) | D. Several hours after breakfast. E. Several hours after lunch. |
| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply.) | A. Basin with warm tap water. B. Gauze pads or washcloth. C. Towel or disposable waterproof barrier. E. Pouch closure device, such as a clamp. Correct |
| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply.) | F. Clean disposable gloves. G. Pouch: clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type with attached skin barrier. |
| Identify interventions for irritation around the stoma. (Select all that apply.) | A. Make sure there is a good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided. C. Determine whether the patient's skin is reacting to adhesive removal. |
| Identify interventions for irritation around the stoma. (Select all that apply.) | D. Consult the ostomy care nurse. E. 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. |
| 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:
colby.caswell