Test 3 Flashcards
A patient that has his entire large intestinge and rectum removed will have what type of ostomy:
A. cecostomy
B. loop colostomy
C. ileostomy
D. descending colostomy
D. Descending colostomy
A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first?
A. measure the stoma
B. cover the stoma with gauze
C. remove the backing on the skin barrier
D. cleanse the stoma and the peristomal skin.
D. cleanse the stoma and the peristomal skin
A patient who has bladder cancer tells the nurse that she prefers a urinary diversion that will allow her to have some control over urinary elimination. Which option will allow that:
A. kock’s pouch
B. ileal conduit
C. cutaneous ureterostomy
D. nephrostomy
A. kock’s pouch
To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to :
A. apply hydrocortisone cream to the skin when changing the appliance.
B..empty the pouch when it is no more than half full.
C. wash the peristomal skin frequently with deodorizing soap and water.
D. Choose a time shortly after a meal for replacing the pouch.
B. empty the pouch when it is no more than half full.
A nurse is administering an enema medicated with Kayexalate to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube
A. 1 to 1.5 in
B. 2 to 3 in
C. 3 to 4 in
D. 4 to 5 in
C. 3 to 4 in.
The nurse explains that the patient should try to retain the instilled oil enema for
A. As long as it takes to complete the procedure.
B. about 10 to 15 min.
C. until the next time he feels the urge to defecate
D. at least 30 min, but preferably as long as he can.
D. at least 30 min, but preferably as long as he can.
A nurse who is administering a return-flow enema to a patient should instill 100 mL of enema fluid and then
A. instruct the patient to retain the fluid
B. lower the container to allow the solution to flow back out.
C. help the patient to the toilet or bedside commode.
D. wait 5 min and instill another 100 mL of fluid
B. lower the container to allow the solution to flow back out.
A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?
A. prone
B. dorsal recumbent
C. right lateral with both knees at chest
D. Left lateral with the right leg flexed.
D. Left lateral with the right leg flexed.
A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?
A. cleansing
B. return-flow
C. medicated
D. oil-retention
B. return-flow
While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?
A. measure the patient’s vital signs
B. notify the primary care provider
C. lower the enema fluid container
D. stop the enema instillation
C. lower the enema fluid container
Because a client is scheduled for a colonoscopy, the nurse will instruct the client to perform which of the following?
A. Oil retention enema
B. Return flow enema
C. High, large volume enema
D. Low, small volume enema
D. Low, small volume enema
Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).
Which of the following is the most appropriate nursing goal for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?
A. The client will wear a medic-alert bracelet for antibiotic allergy.
B. The client will return to his or her previous fecal elimination pattern.
C. The client verbalizes the need to take an antidiarrheal medication prn.
D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.
B. The client will return to his or her previous fecal elimination pattern
The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated.” The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
A. Soapsuds enema
B. Retention enema
C. Return flow enema
D. Oil retention enema
C. Return flow enema
Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.
A nurse in a clinic is reinforcing teaching to a client how to do fecal occult blood testing. Which of the following statements indicates a need for clarification:
A. I will continue my low dose aspirin therapy regimen
B. I will refrain from eating raw fruits and vegetables
C. I will avoid steak and other red meats.
D. I will continue taking my Coumadin as prescribed.
D. I will continue taking my Coumadin as prescribed.
A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. The nurse will instruct the client to empty the appliance:
A. daily at bedtime when connecting to a night drainage system.
B. every 2 hr to prevent leakage
C. twice a day to prevent infection
D. when full to use fewer new appliances
B. every 2 hr to prevent leakage
A nurse in a clinic is preparing information on low fiber diet restrictions for a client who has an ulcerative colitis. Which of the following foods should be eliminated in the client’s diet?
A. cooked cabbage
B. dried apricots
C. ripe bananas
D. ice cream
B. dried apricots
A nurse is reinforcing teaching for a client who is post-operative from having an ileostomy established. Which of the following should the nurse include in the teaching?
A. empty the pouch immediately after meals
B. change the entire appliance once a day
C. limit fluid intake
D. avoid medications in capsule or enteric form
D. avoid medications in capsule or enteric form
Which of the following statements indicates an understanding of collecting a midstream urine sample:
A. I’ll urinate a little then stop
B. I’ll use the cleansing wipe from front to back
C. I’ll dry the outside of the container with a paper towel
D. I’ll use each cleansing wipe twice
B. I’ll use the cleansing wipe from front to back
The stool guaiac testing is for which of the following:
A. bacteria
B. parasites
C. blood
D. fat
C. blood
Which of the following should the nurse instruct a client to avoid for at least three days before a fecal occult blood test:
A. whole grain cereals
B. Milk of Magnesia
C. orange juice
D. Tylenol
C. orange juice
A nurse is monitoring a child for acute signs of lead poisioning. Which of the following should the nurse expect the client to manifest:
A. increased urinary output
B. anorexia
C. diarrhea
D. jaundice
B. anorexia
Which of the following is an appropriate action by the nurse when administering a cleansing enema:
A. keep the container of solution at a level to maintain client comfort.
B. hold the container of solution 12 inches above the anus.
C. hold the container of solution level with the upper hip.
D. slowly lower the container of solution 24 inches below the anus.
B. hold the container of solution 12 inches above the anus.
Which of the following indicates a complication of a restraint:
A. the client has a capillary refill of less than two seconds
B. the client has full range of motion in her wrist
C. the client is attempting to remove the restraint
D. the client’s hand is cool and pale
D. the client’s hand is cool and pale
The first step by the nurse when inserting a indwelling urinary catheter is:
A. use minimal lubrication to minimize friction at the meatus
B. cleanse the urinary meatus before catheterization
C. cleanse the perineal area using back to front motion.
D. irrigate the cteter prior to insertion to assess patency of the catheter.
B. cleanse the urinary meatus before catheterization
