Quiz 15 Elimination And Gastric Intubation

Question 1

A nurse has an order for a removal of an indwelling catheter. What are the correct nursing interventions to prevent injury when removing the catheter?

Answer 1

Deflate the catheter balloon

Question 2

After Foley catheter has been removed, the Nurse assess says the client carefully for?

Answer 2

Urinary tract infection

Question 3

If the solution container for the enema is held above the correct height

Answer 3

Fast running solution causes dis tension and cramping

Question 4

He charge nurse in a long-term care facility is observing another nurse whose inserting indwelling catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?

Answer 4

The nurse separates the clients labia with her dominant hand

Question 5

The nurse has an order for an indwelling catheter insertion on a new client. What is the primary reason for the nurse to use sterile technique?

Answer 5

To avoid introduction of micro organisms

Question 6

The north was preparing to position a mail client for a urinary catheterization. In what position should the nurse place the client?

Answer 6

Supine with thighs slightly abducted

Question 7

The nurse at a healthcare facility is caring for elderly and immobile client with urinary incontinence. The client has been pleased with the Foley catheter. For what purpose is a Foley catheter used in a client?

Answer 7

To maintain skin integrity

Question 8

A nurse is administering a cleansing and I’m a first client who has constipation. Which of the following actions should the nurse take?

Answer 8

What’s a container solution 30 cm or 12 inches above the anus

Question 9

After inserting a nasogastric tube the nurse would check for proper placement by which methods?

Answer 9

Gurgling or swishing sound heard with a stethoscope over the stomach when air is injected into the tube, the ability to aspirate gastric contents with the syringe

Question 10

What is considered a non-invasive method of collecting urine from the incontinence patient

Answer 10

Condom catheterization

Question 11

I nurse is removing the fecal impaction of a client what positioning is recommended for the patient?

Answer 11

Sims

Question 12

Well catheterizing a female client, The nurse answers the catheter into an opening 4to 5 inches and no urine is detected. The most likely reason for this is that?

Answer 12

The catheter is in the vagina

Question 13

What is the correct procedure to test the integrity of the balloon of an indwelling catheter?

Answer 13

Inject and aspirate normal saline or sterile water

Question 14

A nurse is caring for a client who complains of the loss of small amount of urine when she sneezes or laughs. What nursing intervention should the nurse suggest for the client?

Answer 14

Keagle exercises

Question 15

Well receiving a 500 ML soapsuds enema, the client states, I am beginning to feel like I have to go to the bathroom after administering 200 ML’s of solution. Which of the following things would best help the client overcome the urge to defecate?

Answer 15

Clamp the tubing for a short time

Question 16

A nursing student is administering a water and soap solution animal to a client. Which of the following steps should the nurse perform to purge air from the tubing?

Answer 16

Open the clamp and fill the tube with solution

Question 17

The nurse outlines routine catheter care to the nursing assistant as….

Answer 17

Cleaning with soap and water the first 2 inches of the catheter every shift

Question 18

A nurse whose left hand is dominant and is preparing to perform a Catheterization for a client who is a paraplegic. Which of the following actions should the nurse take

Answer 18

Stand on the clients right side

Question 19

A nurse is planning to insert an end to all the catheter for an adult female client. Which of the following actions should the nurse plan to take?

Answer 19

Lubricate the catheter 3 1/2 to 5 cm

Question 20

The nurse is assessing that urine output in a client with an indwelling Foley catheter. Which location is recommended to best assess urine characteristics?

Answer 20

Assess urine in the drainage tubing

Question 21

A nurse is caring for a client who reports constipation. The physician has prescribed an enema, what is the correct order when performing an enema?

Answer 21

Confirm the client identity they checking her arm band, provide for the clients privacy by closing the curtains, assist the client in to Sims position, insert the tip of the enema tubing into the clients rectum

Question 22

The nurse instruct the patient to be diligent in cleaning fecal matter from around the stoma because it can cause which complication?

Answer 22

Irritation of the stoma, skin breakdown around the stoma

Question 23

A nurse is preparing to perform a catheterization to Tina specimen for a client. The client informs the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take?

Answer 23

Close the door and cover the client during the procedure

Question 24

A nurse is administering a tap water enema to a client. The client reports cramping and as the nurse insert solution. Which of the following actions should the nurse take to relieve the clients discomfort?

Answer 24

Lower the height of the solution container

Question 25

When inserting the urinary catheter into a mail client and I’m feeding the balloon, the patient grimaces and looks uncomfortable. What is the appropriate nursing action?

Answer 25

Withdraw fluid from the balloon and advanced catheter Forward

Question 26

When considering the female perineum before catheterization, the nurse will?

Answer 26

Cleanse with strokes from front to back

Question 27

Which of the following clients is at higher risk for fecal impaction?

Answer 27

Bedrest and pour fiber intake

Question 28

A nurse student has been assigned to insert an indwelling catheter in to a mail client. When should the students inflate the balloon during the insertion of the catheter?

Answer 28

After seeing urine in tubing then advance one to 1 1/2 inch more

Question 29

The nurse suspects that the urinary catheter has been accidentally placed in the clients vagina what are the nurses next action?

Answer 29

Leave the catheter in place and is there another sterile catheter into the meatus

Question 30

A nurse is providing instructions to the nurse assistant on the catheter care for this patient. And appropriate instructions asked to

Answer 30

Clean from the urinating meatus down the catheter

Question 31

Bladder training instructions are being given to a patient who has a history of urinary incontinence. The nurse should give the patient which instruction?

Answer 31

Void every one and a half to two hours while you are awake

Question 32

What is the size range for urethral catheter’s?

Answer 32

14 to 24 French

Question 33

What would the nurse do to determine the correct distance to insert a nasogastric tube?

Answer 33

Measure from the tip of the nose to the ear lobe to the syphoid process