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NUR204 exam 5 (5.0 review)
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STUVIA 2024/2025NUR204 exam 5 (5.0 review)
The nurse instructs the patient that the health care provider has
ordered an enema. The patient states, An enema! I'm not constipated. What are other possible
reasons for the order?
(Select all that apply.)
a. Preparation for a diagnostic procedure
b. To increase fluid intake
c. To prevent laxative misuse
d. To administer a medication
e. Preparation for surgery
ade
From the following, choose the correct equipment to bring to the bedside to administer the
commercially prepared Fleet enema. (Select all that apply.)
a. Tubing with a rectal tip
b. Waterproof bed pad
c. Clean disposable gloves
d. Water-soluble lubricant
e. Commercially prepared enema product
f. Toilet paper and/or basin with warm water, washcloth, and towel
%
g. Enema bag
h. Sterile gloves
bcdef
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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?
a. "C. difficile is the organism responsible for duodenal ulcers."
b. "I can reassign you to care for à different patient."
c. "Good hand hygiene with soap and water is your best defense
against C. difficile."
d. "C. difficile can only be acquired through antibiotic therapy,
chemotherapy, or invasive bowel procedures."
c
Which of the following would be inappropriate to delegate to NAP?
a. Recording the amount of ostomy output
b. Administering a tap water enema
c. Pouching a newly established ostomy
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d. Administering a fleet type enema, commercially prepared
c
How often should an ostomy pouch be changed?
a. Every 3 to 7 days
b. Every other day
c. Every two weeks
d. Every 2 to 3 weeks
e. Daily to prevent infection
a
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 difficulty with this change in body
image?
a. The patient continues to rely on the nurse to change the ostomy
pouch
b. Patient holds a gas pad over the stoma while cleaning the peristomal skin
c. The patient is asking many questions
d. The patient is willing to look at the stoma
a
Which of the following is considered a sterile procedure and therefore requires sterile gloves?
%
a. Pouching an ostomy
b. Administering a cleansing enema
c. None of the mentioned
d. Preparing a soapsuds enema for administration
c
The patient is complaining of cramping during instillation of the enema solution. What is the most
appropriate action by
the nurse?
a. Stop the installation and remove the tube from the rectum
b. Raise the height of the enema container
c. Have the patient take deep breath's in and out through the nose
d. Lower the height of the enema container or clamp the tubing until
cramping subsides
d
Which of the following would be considered a normal finding after the administration and evacuation
of an enema?
a. Abdominal distention is absent
b. High pitched, hyperactive bowel sounds are present
c. The patient complains of a firm and painful abdomen
d. The patient passes approximately 50 mL of bright red blood
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a
The nurse is reviewing enema administration with nursing assistive personnel (NAP). Which of the
following statements by the NAP indicates further instruction is necessary?
a. The rectal tube of an enema should be inserted 5 to 7.5 cm or 2 to 3 inches into the rectum of an
adolescent
b. The rectal tube of an enema should be inserted 2.5 to 3.75 cm or
1 to 11/2 inches into the rectum of an infant
c. The rectal tube of an enema should be inserted 5 to 7.5 cm or 2 to
3 inches into the rectum of a child
d. The rectal tube of an enema should be inserted 7.5 to 10 cm or 3
to 4 inches into the rectum of an adult
a
A nurse is preparing to administer an soap suds enema. Which of the following actions indicates
correct understanding?
a. The nurse holds the tubing in the patient's rectum constantly until
the end of fluid installation
b. The nurse places the patient in the prone for enema administration
c. The nurse administers a normal saline enema without a healthcare
providers order when the patient hasn't had a bowel movement
after three days
%
d. The nurse fills the enema bag to the prescribed level with warm
water
a
To which of the following patients would it be considered acceptable to administer an enema without
the nurse needing
to question the order?
a. A patient who is going to have abdominal surgery
b. Patient with increased intracranial pressure
c. A patient with glaucoma
d. Patient with inflammatory bowel disease
a
The nurse listens for bowel sounds before administering an enema. The patient asks, "Why are you
listening to my
abdomen?" The nurse's accurate response is:
a. To determine the presence of bowel sounds, which indicates you
will be able to hold the solution
b. To determine which position I should place you in for
administration of the enema
c. To determine the presence of bowel sounds which indicates the
intestines are working
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d. To determine the amount of enema solution needed
c
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.)
a. The patient eats whole grains, raw fruits, and green leafy vegetables
b. The patient is an elderly woman
c. The patient reports daily exercise and remains active
d. The patient takes daily iron and calcium supplements
e. The patient reports rare laxative use
f. The patient takes opioids for chronic pain
bdf
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
Hypertension
B
Tachycardia
%
C
A decrease in respirations
D
Bradycardia
d
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?
a. The patient had a vagal response
b. Diarrhea as a result of decreased muscle tone
c. Flatulence
d. Impaction
d
An increase in venous pressure caused by liver disease can result in the development of:
a. Hemorrhoids
b. Flatulence
c. Diarrhea
d. Impaction
a
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