NR 224 Fundamentals Final Review Questions and Answers (2023/ 2024 Update) - Chamberlain

NR 224 Fundamentals Final Review Questions and Answers (2023/ 2024 Update) - Chamberlain What is the most effective method to prevent the transfer of clostridium difficile (C. Difficile)? - ANSWER HAND HYGIENE with soap and water is effective to physically remove C. difficile spores from the hands. (Potter 1092) What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a forced expiration against a closed airway? - ANSWER Valsalva maneuver *Normal passage of bowels should be painless, passing soft formed stool* Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the Valsalva maneuver and MUST avoid straining to pass stool? - ANSWER Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound (Potter 1089) What is the term for a collection of hardened feces in the rectum that cannot be expelled due to unrelieved constipation? - ANSWER Fecal Impaction Where does fecal impaction occur in the colon? - ANSWER Rectum Least formed stool is present in which portion of the digestive tract? - ANSWER Ascending Colon Most formed stool is present in which portion of the digestive tract? - ANSWER Descending Colon Which position should the patient be in while administering an enema? - ANSWER Left Side-Lying or Sim's Position Which factors would contribute to stopping enema administration? - ANSWER If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is felt Which enema solution is the safest for administration because it does NOT create a danger for excess fluid absorption? - ANSWER Normal Saline [Isotonic Solution] Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk for fluid imbalance? - ANSWER Hypertonic Solution Which enema solution is considered to be hypotonic and should NOT be repeated because of the risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts of water? - ANSWER Tap Water [Hypotonic Solution] Which enema solution lubricates the rectum and allows the feces to absorb the oil making them soft and easier to pass? - ANSWER Oil Retention Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap? - ANSWER Soapsuds Which enema solution should be used in caution in pregnant women and elderly because it may cause an electrolyte imbalance or damage to intestinal mucosa? - ANSWER Soapsuds Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that cannot be seen) - ANSWER Guaiac Fecal Occult Blood Test Repeat the test at least three times while the patient refrains from ingesting foods (e.g., some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, non-steroidal anti-inflammatory drugs) that cause false-positive results (Potter 1100) When analyzing a fecal specimens for ova and parasites, what is required of the stool? - ANSWER The stool MUST be warm. If the stool specimen remains at room temperature, bacteriological changes can alter the test results Which cathartic form is most effective because of its stimulant effect on the rectal mucosa? (Example: Dulcolax)? - ANSWER Cathartic Suppositories Which foods induce a constipating effect? - ANSWER cheese, lean meats, eggs, and pasta Which food induce a laxative effect? - ANSWER fruits, vegetables, bran, chocolate, alcohol, and coffee What are the assessment findings of a normal stoma? - ANSWER bright pink or brick red