NUR204 exam 5 (5.0 review)
j j j j
Thejnursejinstructsjthejpatientjthatjthejhealthjcarejproviderjhas
orderedjanjenema.jThejpatientjstates,jAnjenema!jI'mjnotjconstipated.jWhatjarejotherjpossiblejreasonsjforjth
ejorder?
(Selectjalljthatjapply.)
a. Preparationjforjajdiagnosticjprocedure
b. Tojincreasejfluidjintake
c. Tojpreventjlaxativejmisuse
d. Tojadministerjajmedication
e. Preparationjforjsurgeryj
ajdje
Fromjthejfollowing,jchoosejthejcorrectjequipmentjtojbringjtojthejbedsidejtojadministerjthejcommerciallyjprep
aredjFleetjenema.j(Selectjalljthatjapply.)
a. Tubingjwithjajrectaljtip
b. Waterproofjbedjpad
c. Cleanjdisposablejgloves
d. Water-solublejlubricant
e. Commerciallyjpreparedjenemajproduct
f. Toiletjpaperjand/orjbasinjwithjwarmjwater,jwashcloth,jandjtowel
g. Enemajbag
h. Sterilejglovesj
bjcjdjejf
ThejNAPjtellsjthejnursejshejdoesn'tjwantjtojcarejforjajcertainjpatientjbecausejshejisjafraidjofjcontractingjC.jdif
ficile.
Whichjisjthejbestjresponsejbyjthejnurse?
a. "C.jdifficilejisjthejorganismjresponsiblejforjduodenaljulcers."
b. "Ijcanjreassignjyoujtojcarejforjàjdifferentjpatient."
c. "Goodjhandjhygienejwithjsoapjandjwaterjisjyourjbestjdefensejagai
nstjC.jdifficile."
d. "C.jdifficilejcanjonlyjbejacquiredjthroughjantibioticjtherapy,jch
emotherapy,jorjinvasivejboweljprocedures."
c
WhichjofjthejfollowingjwouldjbejinappropriatejtojdelegatejtojNAP?
a. Recordingjthejamountjofjostomyjoutput
b. Administeringjajtapjwaterjenema
c. Pouchingjajnewlyjestablishedjostomy
,d. Administeringjajfleetjtypejenema,jcommerciallyjpreparedjc
Howjoftenjshouldjanjostomyjpouchjbejchanged?
a. Everyj3jtoj7jdays
b. Everyjotherjday
c. Everyjtwojweeks
d. Everyj2jtoj3jweeks
e. Dailyjtojpreventjinfectionja
Thejnursejunderstandsjthejimportantjrolejinjhelpingjthejpatientjwithjanjostomyjacceptjtheirjchangejinjself-
image.jWhich
ofjthejfollowingjindicatesjthejpatientjisjhavingjdifficultyjwithjthisjchangejinjbodyjimage?
a. Thejpatientjcontinuesjtojrelyjonjthejnursejtojchangejthejostomyjpouc
h
b. Patientjholdsjajgasjpadjoverjthejstomajwhilejcleaningjthejperistomaljskin
c. Thejpatientjisjaskingjmanyjquestions
d. Thejpatientjisjwillingjtojlookjatjthejstomaja
Whichjofjthejfollowingjisjconsideredjajsterilejprocedurejandjthereforejrequiresjsterilejgloves?
a. Pouchingjanjostomy
b. Administeringjajcleansingjenema
c. Nonejofjthejmentioned
d. Preparingjajsoapsudsjenemajforjadministrationjc
Thejpatientjisjcomplainingjofjcrampingjduringjinstillationjofjthejenemajsolution.jWhatjisjthejmostjappropriatej
actionjby
thejnurse?
a. Stopjthejinstallationjandjremovejthejtubejfromjthejrectum
b. Raisejthejheightjofjthejenemajcontainer
c. Havejthejpatientjtakejdeepjbreath'sjinjandjoutjthroughjthejnose
d. Lowerjthejheightjofjthejenemajcontainerjorjclampjthejtubingjuntiljcra
mpingjsubsides
d
Whichjofjthejfollowingjwouldjbejconsideredjajnormaljfindingjafterjthejadministrationjandjevacuationjofjanje
nema?
a. Abdominaljdistentionjisjabsent
b. Highjpitched,jhyperactivejboweljsoundsjarejpresent
c. Thejpatientjcomplainsjofjajfirmjandjpainfuljabdomen
d. Thejpatientjpassesjapproximatelyj50jmLjofjbrightjredjblood
,a
Thejnursejisjreviewingjenemajadministrationjwithjnursingjassistivejpersonnelj(NAP).jWhichjofjthejfollowingj
statementsjbyjthejNAPjindicatesjfurtherjinstructionjisjnecessary?
a. Thejrectaljtubejofjanjenemajshouldjbejinsertedj5jtoj7.5jcmjorj2jtoj3jinchesjintojthejrectumjofjanjadolesce
nt
b. Thejrectaljtubejofjanjenemajshouldjbejinsertedj2.5jtoj3.75jcmjorj1jtoj1
1/2jinchesjintojthejrectumjofjanjinfant
c. Thejrectaljtubejofjanjenemajshouldjbejinsertedj5jtoj7.5jcmjorj2jtoj3jinch
esjintojthejrectumjofjajchild
d. Thejrectaljtubejofjanjenemajshouldjbejinsertedj7.5jtoj10jcmjorj3jtoj4jin
chesjintojthejrectumjofjanjadult
a
Ajnursejisjpreparingjtojadministerjanjsoapjsudsjenema.jWhichjofjthejfollowingjactionsjindicatesjcorrectjunde
rstanding?
a. Thejnursejholdsjthejtubingjinjthejpatient'sjrectumjconstantlyjuntiljthej
endjofjfluidjinstallation
b. Thejnursejplacesjthejpatientjinjthejpronejforjenemajadministration
c. Thejnursejadministersjajnormaljsalinejenemajwithoutjajhealthcarejpro
vidersjorderjwhenjthejpatientjhasn'tjhadjajboweljmovement
afterjthreejdays
d. Thejnursejfillsjthejenemajbagjtojthejprescribedjleveljwithjwarmjwate
r
a
Tojwhichjofjthejfollowingjpatientsjwouldjitjbejconsideredjacceptablejtojadministerjanjenemajwithoutjthejnurs
ejneeding
tojquestionjthejorder?
a. Ajpatientjwhojisjgoingjtojhavejabdominaljsurgery
b. Patientjwithjincreasedjintracranialjpressure
c. Ajpatientjwithjglaucoma
d. Patientjwithjinflammatoryjboweljdiseaseja
Thejnursejlistensjforjboweljsoundsjbeforejadministeringjanjenema.jThejpatientjasks,j"Whyjarejyoujlisteningj
tojmy
abdomen?"jThejnurse'sjaccuratejresponsejis:
a. Tojdeterminejthejpresencejofjboweljsounds,jwhichjindicatesjyoujwillj
bejablejtojholdjthejsolution
b. TojdeterminejwhichjpositionjIjshouldjplacejyoujinjforjad
ministrationjofjthejenema
c. Tojdeterminejthejpresencejofjboweljsoundsjwhichjindicatesjthejinte
stinesjarejworking
, d. Tojdeterminejthejamountjofjenemajsolutionjneededjc
Ajnursejisjadmittingjajpatientjtojthejunit.jThejnursejisjawarejthatjthejpatientjisjatjincreasedjriskjforjconstipatio
njifjthe
followingjare
presentjinjthejpatient'sjhealthjhistoryjorjadmissionjassessment:j(Selectjalljthatjapply.)
a. Thejpatientjeatsjwholejgrains,jrawjfruits,jandjgreenjleafyjvegetables
b. Thejpatientjisjanjelderlyjwoman
c. Thejpatientjreportsjdailyjexercisejandjremainsjactive
d. Thejpatientjtakesjdailyjironjandjcalciumjsupplements
e. Thejpatientjreportsjrarejlaxativejuse
f. Thejpatientjtakesjopioidsjforjchronicjpainjbj
djf
Thejnursejisjmonitoringjthejpatientjforjajpossiblejvagaljresponsejwhilejremovingjajfecaljimpaction.jIfjthejpati
entjhadja
vagaljresponse,jwhatjwouldjthejnursejmostjlikelyjobserve?jA
Hypertensionj
B
Tachycardiaj
C
AjdecreasejinjrespirationsjD
Bradycardiaj
d
Thejcomatosejpatientjinjthejintensivejcarejunitj(ICU),jwhojhasjnotjhadjajboweljmovementjinj4jdays,jsuddenl
yjis
incontinentjofjliquidjstool.jWhatjshouldjthejnursejsuspect?
a. Thejpatientjhadjajvagaljresponse
b. Diarrheajasjajresultjofjdecreasedjmusclejtone
c. Flatulence
d. Impactionj
d
Anjincreasejinjvenousjpressurejcausedjbyjliverjdiseasejcanjresultjinjthejdevelopmentjof:
a. Hemorrhoids
b. Flatulence
c. Diarrhea
d. Impactionj
a
j j j j
Thejnursejinstructsjthejpatientjthatjthejhealthjcarejproviderjhas
orderedjanjenema.jThejpatientjstates,jAnjenema!jI'mjnotjconstipated.jWhatjarejotherjpossiblejreasonsjforjth
ejorder?
(Selectjalljthatjapply.)
a. Preparationjforjajdiagnosticjprocedure
b. Tojincreasejfluidjintake
c. Tojpreventjlaxativejmisuse
d. Tojadministerjajmedication
e. Preparationjforjsurgeryj
ajdje
Fromjthejfollowing,jchoosejthejcorrectjequipmentjtojbringjtojthejbedsidejtojadministerjthejcommerciallyjprep
aredjFleetjenema.j(Selectjalljthatjapply.)
a. Tubingjwithjajrectaljtip
b. Waterproofjbedjpad
c. Cleanjdisposablejgloves
d. Water-solublejlubricant
e. Commerciallyjpreparedjenemajproduct
f. Toiletjpaperjand/orjbasinjwithjwarmjwater,jwashcloth,jandjtowel
g. Enemajbag
h. Sterilejglovesj
bjcjdjejf
ThejNAPjtellsjthejnursejshejdoesn'tjwantjtojcarejforjajcertainjpatientjbecausejshejisjafraidjofjcontractingjC.jdif
ficile.
Whichjisjthejbestjresponsejbyjthejnurse?
a. "C.jdifficilejisjthejorganismjresponsiblejforjduodenaljulcers."
b. "Ijcanjreassignjyoujtojcarejforjàjdifferentjpatient."
c. "Goodjhandjhygienejwithjsoapjandjwaterjisjyourjbestjdefensejagai
nstjC.jdifficile."
d. "C.jdifficilejcanjonlyjbejacquiredjthroughjantibioticjtherapy,jch
emotherapy,jorjinvasivejboweljprocedures."
c
WhichjofjthejfollowingjwouldjbejinappropriatejtojdelegatejtojNAP?
a. Recordingjthejamountjofjostomyjoutput
b. Administeringjajtapjwaterjenema
c. Pouchingjajnewlyjestablishedjostomy
,d. Administeringjajfleetjtypejenema,jcommerciallyjpreparedjc
Howjoftenjshouldjanjostomyjpouchjbejchanged?
a. Everyj3jtoj7jdays
b. Everyjotherjday
c. Everyjtwojweeks
d. Everyj2jtoj3jweeks
e. Dailyjtojpreventjinfectionja
Thejnursejunderstandsjthejimportantjrolejinjhelpingjthejpatientjwithjanjostomyjacceptjtheirjchangejinjself-
image.jWhich
ofjthejfollowingjindicatesjthejpatientjisjhavingjdifficultyjwithjthisjchangejinjbodyjimage?
a. Thejpatientjcontinuesjtojrelyjonjthejnursejtojchangejthejostomyjpouc
h
b. Patientjholdsjajgasjpadjoverjthejstomajwhilejcleaningjthejperistomaljskin
c. Thejpatientjisjaskingjmanyjquestions
d. Thejpatientjisjwillingjtojlookjatjthejstomaja
Whichjofjthejfollowingjisjconsideredjajsterilejprocedurejandjthereforejrequiresjsterilejgloves?
a. Pouchingjanjostomy
b. Administeringjajcleansingjenema
c. Nonejofjthejmentioned
d. Preparingjajsoapsudsjenemajforjadministrationjc
Thejpatientjisjcomplainingjofjcrampingjduringjinstillationjofjthejenemajsolution.jWhatjisjthejmostjappropriatej
actionjby
thejnurse?
a. Stopjthejinstallationjandjremovejthejtubejfromjthejrectum
b. Raisejthejheightjofjthejenemajcontainer
c. Havejthejpatientjtakejdeepjbreath'sjinjandjoutjthroughjthejnose
d. Lowerjthejheightjofjthejenemajcontainerjorjclampjthejtubingjuntiljcra
mpingjsubsides
d
Whichjofjthejfollowingjwouldjbejconsideredjajnormaljfindingjafterjthejadministrationjandjevacuationjofjanje
nema?
a. Abdominaljdistentionjisjabsent
b. Highjpitched,jhyperactivejboweljsoundsjarejpresent
c. Thejpatientjcomplainsjofjajfirmjandjpainfuljabdomen
d. Thejpatientjpassesjapproximatelyj50jmLjofjbrightjredjblood
,a
Thejnursejisjreviewingjenemajadministrationjwithjnursingjassistivejpersonnelj(NAP).jWhichjofjthejfollowingj
statementsjbyjthejNAPjindicatesjfurtherjinstructionjisjnecessary?
a. Thejrectaljtubejofjanjenemajshouldjbejinsertedj5jtoj7.5jcmjorj2jtoj3jinchesjintojthejrectumjofjanjadolesce
nt
b. Thejrectaljtubejofjanjenemajshouldjbejinsertedj2.5jtoj3.75jcmjorj1jtoj1
1/2jinchesjintojthejrectumjofjanjinfant
c. Thejrectaljtubejofjanjenemajshouldjbejinsertedj5jtoj7.5jcmjorj2jtoj3jinch
esjintojthejrectumjofjajchild
d. Thejrectaljtubejofjanjenemajshouldjbejinsertedj7.5jtoj10jcmjorj3jtoj4jin
chesjintojthejrectumjofjanjadult
a
Ajnursejisjpreparingjtojadministerjanjsoapjsudsjenema.jWhichjofjthejfollowingjactionsjindicatesjcorrectjunde
rstanding?
a. Thejnursejholdsjthejtubingjinjthejpatient'sjrectumjconstantlyjuntiljthej
endjofjfluidjinstallation
b. Thejnursejplacesjthejpatientjinjthejpronejforjenemajadministration
c. Thejnursejadministersjajnormaljsalinejenemajwithoutjajhealthcarejpro
vidersjorderjwhenjthejpatientjhasn'tjhadjajboweljmovement
afterjthreejdays
d. Thejnursejfillsjthejenemajbagjtojthejprescribedjleveljwithjwarmjwate
r
a
Tojwhichjofjthejfollowingjpatientsjwouldjitjbejconsideredjacceptablejtojadministerjanjenemajwithoutjthejnurs
ejneeding
tojquestionjthejorder?
a. Ajpatientjwhojisjgoingjtojhavejabdominaljsurgery
b. Patientjwithjincreasedjintracranialjpressure
c. Ajpatientjwithjglaucoma
d. Patientjwithjinflammatoryjboweljdiseaseja
Thejnursejlistensjforjboweljsoundsjbeforejadministeringjanjenema.jThejpatientjasks,j"Whyjarejyoujlisteningj
tojmy
abdomen?"jThejnurse'sjaccuratejresponsejis:
a. Tojdeterminejthejpresencejofjboweljsounds,jwhichjindicatesjyoujwillj
bejablejtojholdjthejsolution
b. TojdeterminejwhichjpositionjIjshouldjplacejyoujinjforjad
ministrationjofjthejenema
c. Tojdeterminejthejpresencejofjboweljsoundsjwhichjindicatesjthejinte
stinesjarejworking
, d. Tojdeterminejthejamountjofjenemajsolutionjneededjc
Ajnursejisjadmittingjajpatientjtojthejunit.jThejnursejisjawarejthatjthejpatientjisjatjincreasedjriskjforjconstipatio
njifjthe
followingjare
presentjinjthejpatient'sjhealthjhistoryjorjadmissionjassessment:j(Selectjalljthatjapply.)
a. Thejpatientjeatsjwholejgrains,jrawjfruits,jandjgreenjleafyjvegetables
b. Thejpatientjisjanjelderlyjwoman
c. Thejpatientjreportsjdailyjexercisejandjremainsjactive
d. Thejpatientjtakesjdailyjironjandjcalciumjsupplements
e. Thejpatientjreportsjrarejlaxativejuse
f. Thejpatientjtakesjopioidsjforjchronicjpainjbj
djf
Thejnursejisjmonitoringjthejpatientjforjajpossiblejvagaljresponsejwhilejremovingjajfecaljimpaction.jIfjthejpati
entjhadja
vagaljresponse,jwhatjwouldjthejnursejmostjlikelyjobserve?jA
Hypertensionj
B
Tachycardiaj
C
AjdecreasejinjrespirationsjD
Bradycardiaj
d
Thejcomatosejpatientjinjthejintensivejcarejunitj(ICU),jwhojhasjnotjhadjajboweljmovementjinj4jdays,jsuddenl
yjis
incontinentjofjliquidjstool.jWhatjshouldjthejnursejsuspect?
a. Thejpatientjhadjajvagaljresponse
b. Diarrheajasjajresultjofjdecreasedjmusclejtone
c. Flatulence
d. Impactionj
d
Anjincreasejinjvenousjpressurejcausedjbyjliverjdiseasejcanjresultjinjthejdevelopmentjof:
a. Hemorrhoids
b. Flatulence
c. Diarrhea
d. Impactionj
a
