Bowel Elimination / Ostomy Care, Urinary Catheterization, Module 17: Lesson 6 Post-Test, NU 311 EXAM 4 Urinary Cath, Evolve - Urination, Module 16 Urinary, N220: Oxygenation video quizzes, Hallmark final exam BSN-205

Bowel Elimination / Ostomy Care, Urinary Catheterization, Module 17: Lesson 6 Post-Test, NU 311 EXAM 4 Urinary Cath, Evolve - Urination, Module 16 Urinary, N220: Oxygenation video quizzes, Hallmark final exam BSN-205 Primary function of the GI structure: 1. Esophagus 2. Rectum 3. Small Intestine 4. Stomach 5. Colon 1. Where peristalsis moves food to the stomach. 2. Temporarily stores feces until elimination. 3. Receives enzymes from the gallbladder and pancreas to further break down chyme and absorb nutrients. 4. Secretes hydrochloric acid and pepsin; converts bolus of food to chyme. 5. Absorbs, protects, secretes, eliminates. Rationale: The esophagus moves food to the stomach by peristaltic action. The stomach secretes hydrochloric acid and pepsin and converts the food bolus to chyme. The small intestine receives enzymes from the gallbladder and pancreas to further break down chyme. Most absorption of nutrients occurs in the small intestine. The primary functions of the colon (large intestine) are absorption, protection, secretion, and elimination. The rectum temporarily stores feces until elimination. If a patient had to have part of the colon (large intestine) removed, which of the following may result? The patient could experience an acid-base imbalance. Rationale: A primary function of the colon is secretion of bicarbonate for chloride and the release of potassium. Any alteration in secretory function could result in an acid-base imbalance. Another primary function of the colon is protection of the sensitive tissue lining of the colon through the release of mucus. If a portion of the colon is removed, there would be fewer mucus-secreting cells available. The colon also absorbs water, sodium, and chloride. If less water is absorbed, the patient would be at increased risk for diarrhea and an electrolyte imbalance. 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 that apply. - the patient is an elderly woman - the patient takes opioids for chronic back pain - the patient takes daily iron and calcium supplements Rationale: As a person ages, peristalsis slows, which increases the risk for constipation. Opioids, iron supplements, and calcium supplements slow colonic action. Laxative misuse is a common cause for constipation. A diet high in animal fats and low in fiber and fluid increases the risk for constipation. Lengthy bed rest or lack of regular exercise are risk factors for constipation. A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding? "The ascending colon would be found in the right side of the patient's abdomen." Rationale: The ascending colon is found in the right side of the abdomen. The order of the colon is ascending colon, transverse colon, descending colon, sigmoid colon (then rectum and anus). Most nutrients are absorbed in the small intestine; most water is absorbed in the large intestine. A patient's heart rate may decrease with manipulation of the rectum that stimulates the vagus nerve (known as a vagal response). Opioids (narcotic analgesics) cause constipation because of decreasing peristalsis; antibiotic therapy places a person at risk for diarrhea as a result of altered normal flora (as seen with Clostridium difficile infection). An increase in venous pressure caused by liver disease can result in the development of: Hemorrhoids Rationale: Pressure leading to hemorrhoids can also occur from straining during defecation and from pregnancy. The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? Impaction Rationale: Prolonged constipation followed by diarrhea that seeps around the impacted stool are symptoms of a fecal impaction. 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? A decrease in heart rate Rationale: The nurse should monitor the patient for a decrease in heart rate. An adult patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: 1000 mL or less of tap water Rationale: A tap water enema usually contains 750 to 1000 mL for the adult. If castile soap were to be added, the order would be for a soap suds enema. A Fleet enema is a hypertonic enema and that would be noted on the order. Because the order is for a tap water enema, the Fleet product would not be appropriate. The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? The nurse squeezes and releases the bottle several times until all of the solution has entered the patient Rationale: Squeezing and releasing the bottle would create suction within the patient's rectum as fluid would attempt to fill the negative pressure within the bottle. The pliable bottle should be squeezed gently and rolled up from the bottom as the contents enter the bowel. If too cold, the enema solution should be warmed to prevent abdominal cramping. The protective cover should be removed to avoid accidental instillation of the cap into the patient. The rectal tip is prelubricated, but more water-soluble jelly may be added if needed. An adult patient complains of cramping during the administration of an enema. What could be a possible cause? Select all that apply. - the solution was instilled too rapidly - the enema solution was too cold Rationale: One of the reasons for cramping is too rapid instillation of the solution. Slow the flow of the solution by lowering the enema container. A cold solution may also cause abdominal cramping. The patient should be in Sims' position and the lubricated rectal tip inserted 3 to 4 inches. Which of the following is the best example of documentation of enema administration? 0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended. Patient states "I'm glad that's over." Rationale: Documentation of enema administration should include the type of enema given; amount of fluid; characteristics of the fecal return; assessments before, during, and after the procedure; any calls placed to health care provider; and patient's tolerance of the procedure. The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP, would require correction? The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it Rationale: The lubricated tip of the rectal tube should be inserted 3 to 4 inches on an adult (7.5 to 10 cm). Insertion beyond the proper limit could cause bowel perforation. The fluid bag is typically placed 12 to 18 inches above the level of the patient's anus. The patient should be placed in the Sims' position to allow the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving retention of the solution. Priming the tubing removes air from the tubing. A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? Administer a third enema Rationale: The nurse should administer a third enema. If the nurse continues to see fecal matter in the third return, the health care provider should be notified because too many large-volume enemas can cause a serious fluid and electrolyte imbalance. An infant is to have an enema. Which solution would the nurse anticipate using? Normal saline Rationale: Normal saline is the safest type of solution. Infants and children can tolerate only this type because of their predisposition to fluid imbalance. The nurse is catheterizing a male patient. Which of the following demonstrates correct understanding of the procedure? (Select all that apply.) - The patient is placed in a supine position with legs slightly abducted. - The nurse cleans the urethral meatus using a circular motion beginning at the meatus and working outward in a spiral pattern. - The nurse applies sterile gloves before opening the antiseptic solution and lubricant. Match the clinical situation with the intervention: (A) Apply condom catheter- Patient is an incontinent male who empties his bladder fully (B) Consider prostate enlargement; may require Coudé catheter- Difficulty inserting catheter with a male patient (C) Insert indwelling catheter- Patient is going to have major abdominal surgery (D) Patient is due to void between 4:00 PM and 6:00 PM- Indwelling catheter is removed at 10 AM (E) Ensure tubing/catheter is kink free, then assess patient for renal failure or for severe dehydration- Urine output from indwelling catheter is less than 30 mL per hour (F) Notify health care provider- Patient with indwelling catheter develops fever, elevated pulse, lower abdominal pain, cloudy, foul-smelling urine (G) Document the procedure- 16 French 5 mL indwelling catheter inserted; tolerated well; output of 875 mL clear, yellow urine; pain free; urine specimen sent to lab (H) Insert straight catheter- Patient needs a single sterile urine specimen Match the type of catheter to the type of application: (A) Incontinent male who is able to void completely-3 (B) Temporary catheterization to obtain a sterile sample from patient unable to void-1 (C) Long-term catheterization on male with enlarged prostate-2 Match the urinary catheter preparation description to the sex of the patient: (A) Gently retract the labia and expose the urinary meatus- Female (B) Lubricate the catheter 12.5 to 17.5 cm (5 to 7 inches)-Male (C) Abduct legs during positioning-Male (D) Advance the catheter to bifurcation of drainage and balloon port-Male (E) Wipe around the urethral meatus in a circular motion-Male (F) Position with knees flexed with slight external rotation of the hips-Female (G) Wipe from the clitoris toward the anus-Female (H) Lubricate catheter 2.5 to 5 cm (1 to 2 inches)-Female (I) Gently retract foreskin, exposing urinary meatus-Male (J) Advance catheter 5 to 7.5 cm (2 to 3 inches)-Female A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His health care provider has ordered the insertion of a catheter to determine the amount of residual urine and then to remain in place to assist him with voiding during this post-trauma period. What type of urinary catheter should the nurse anticipate using? An indwelling catheter Which of the following requires strict surgical asepsis? Insertion of an indwelling catheter Identify the procedures that may be delegated to NAP: (Select all that apply.) - Application of a condom catheter - Perform a bladder scan - Care of an indwelling catheter The nurse is assisting the NAP to remove an indwelling catheter. The nurse should intervene if which of the following actions is noted? The NAP: cleans the patient's perineal area, hands the patient their call light, and removes gloves. The nurse has received an order to insert an indwelling catheter in a 24-year-old female patient. Which catheter would be most appropriate for this patient? 14 Fr 5 mL balloon Place the steps in correct order for inserting an indwelling catheter in a male patient: 1. Wash hands. Position the patient. Open catheter kit. 2. Place drainage bag over bed frame, place drape under patient, apply sterile gloves. Place fenestrated drape. 3. Lubricate end of catheter, open antiseptic and pour over cotton balls. 4. Hold penis with nondominant hand, use forceps and antiseptic cotton ball with dominant hand to clean meatus in a circular motion three times using new cotton ball each time. 5. Insert catheter to bifurcation, inflate balloon. Pull back on catheter until resistance is felt. 6. Connect to bedside drainage bag. Secure catheter with tape. 7. Discard supplies. Wash hands. Document. The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) It is relatively safe and noninvasive. It is a convenient method of draining urine. It is used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter. Which of the following would be inappropriate to delegate to NAP? Indwelling catheter insertion. Which of the following could be considered negligence? A regular condom catheter is removed every 3 days. During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse's best action? Obtain another adhesive strip from condom catheter kit. The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed? Redness and/or excoriation of the penis The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds: "The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied." Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) A. An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. B. A patient drinks an entire pitcher of water over the period of 1 day. C. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap D. The NAP places a patient's drainage bag on a lowered side rail or on the floor. E. A female patient keeps her catheter secured to her thigh with tape. A. An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. Correct C. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. Correct D. The NAP places a patient's drainage bag on a lowered side rail or on the floor. Correct ***The urinary drainage bag should be kept below the level of the bladder to prevent reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the level of the bladder and to secure the drainage bag to the side of the wheelchair below the level of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail because it could accidentally be raised to a height higher than the level of the bladder and urine could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should be encouraged. The catheter should be secured to the patient to prevent trauma to the urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary tract infection. Which of the following are true regarding the impact of aging related to urinary elimination? (Select all that apply.) A. The elderly are better able to concentrate urine than the middle-aged adult. B. Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. C. The elderly are less likely to experience urinary frequency than middle-aged adults because they tend to drink less. D. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. E. It is part of the normal aging process for elderly patients to become incontinent. B. Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. Correct D. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. Correct During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern? The kidneys assist in the detoxification of medication metabolites. ***The kidneys detoxify and eliminate by products of medication metabolism. If the kidneys are unable to perform this function, medication toxicity can develop. The nephron, the functional unit of the kidney, forms the urine. The bladder holds the urine until it is excreted. The liver is a primary site for medication metabolism. The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed? A. "The urinary tract is considered to be sterile." B. "The nurse may use clean technique to insert an indwelling catheter." C. "The urge to void is felt when the bladder contains 150 to 200 mL in an adult." D. "The minimum average hourly urine output is 30 mL." B. "The nurse may use clean technique to insert an indwelling catheter." Correct ****Sterile technique is used whether inserting a straight or indwelling urinary catheter. Patients may use clean insertion technique in the home setting for intermittent catheterization. When the patient is in an acute care or long-term care setting, sterile insertion technique is required because of the high risk for nosocomial infections. The urinary tract is sterile. The desire to urinate can be sensed when the bladder contains a smaller amount of urine (150 to 200 mL in an adult and 50 to 100 mL in a child). Minimum average hourly output is 30 mL.