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NCO BowelPOST-TEST 2
Question | Answer |
---|---|
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." |