Nightingale BSN 205, Elimination ISB (Bowel/Ostomy Care)
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each of the black spaces below before clicking
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| show | Lubricate the first 6-8cm (2.5-3 inches) of the tip of the tube
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| show | Perform hand hygiene before donning gloves.
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| Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? | show 🗑
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| show | It may take three or four enemas to achieve a clear return.
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| show | I'll instill the solution and then check in on my other patients until i get the call signal.
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| show | The patient could experience an acid-base imbalance.
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| 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) | show 🗑
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| show | The ascending colon would be found in the right side of the patient's abdomen.
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| An increase in venous pressure caused by liver disease can result in the development of: | show 🗑
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| show | Impaction
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| 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? | show 🗑
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| show | 1000 mL or less of tap water
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| show | The nurse squeezes and released the bottle several times until all of the solution has entered the patient.
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| show | The solution was instilled too rapidly. The enema solution was too cold
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| show | 0830 800mL of tap water enema administered. Return clear w/ no fecal material. Bowel sounds present in all 4 quadrants pre and post procedure`. Abdomen nondistended. Patient states "I'm glad that's over."
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| show | The NAP inserts the tip of the rectal tube 5-7 inches after lubricating it.
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| show | Administer a third enema
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| An infant is to have an enema. Which solution would the nurse anticipate using? | show 🗑
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| A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucous. What is your best response? | show 🗑
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| 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? | show 🗑
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| show | "Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times."
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| The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect? | show 🗑
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| show | Several hours after breakfast. Several hours after lunch.
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| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select All) | show 🗑
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| Identify interventions for irritation around the stoma. (Select all that apply.) | show 🗑
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| Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? | show 🗑
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| From the following, choose the four primary functions of the colon. (Select All) | show 🗑
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| From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared fleet enema. (Select All) | show 🗑
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| The nurse listens for bowel sounds before administering an enema. The patient asks, "why are you listening to my abdomen?" The nurses accurate response is: | show 🗑
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| show | A patient who is going to have abdominal surgery.
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| A nurse is preparing to administer an enema. Which of the following indicates correct understanding? | show 🗑
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| The nurse is reviewing enema administration w/ NAP. Which of the following statements by the NAP indicates further instruction is necessary? | show 🗑
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| show | Abdominal distention is absent.
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| The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse? | show 🗑
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| show | None of the above.
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| The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficult with this change in body image? | show 🗑
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| show | Every 3 to 7 days.
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| show | "The stoma typically increases in size with the passage of time."
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| Which of the following would be inappropriate to delegate to the NAP? | show 🗑
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| The NAP tells the nurse she doesn't want to care for a certain patient because she is afraid of contracting C. difficile. Which is the best response by the nurse? | show 🗑
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| show | To administer a medication. Preparation for surgery. Preparation for diagnostic procedure.
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