NR 224: Final Exam Prep (Answered) 239
Questions and Correct Answers, 100%
Correct, Latest Fall 2024/2025.
What is the most effective method to prevent the transfer of clostridium difficile (C. Difficile) ?
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?
Valsalva Manuever
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
manuever and MUST avoid straining to pass stool?
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?
Fecal Impaction
Where does fecal impaction occur in the colon?
Rectum
Least formed stool is present in which portion of the digestive tract?
Ascending Colon
Most formed stool is present in which portion of the digestive tract?
Descending Colon
Which position should the patient be in while administering an enema?
Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration?
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?
Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk
for fluid imbalance?
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?
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?
Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap?
Soapsuds
Which enema solution should used in caution in pregnant women and elderly because it may cause an
electrolyte imbalance or damage to intestinal mucosa?
Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that cannot
be seen)
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?
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)?
,Cathartic Suppositories
Which foods induce a constipating effect?
cheese, lean meats, eggs, and pasta
Which food induce a laxative effect?
fruits, vegetables, bran, chocolate, alcohol, and coffee
What are the assessment findings of a normal stoma?
bright pink or brick red
Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem to the stoma
How does the nurse measure the length of the NG tube for insertion?
Tip of the nose --> earlobe --> xiphoid process
What is the most reliable method of verification for placement of the NG tube?
X-ray
Other methods include: pH test (aspirate and inspect color)
When energy requirements are completely met or EQUALS kcal intake in food what occurs?
Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs?
Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs?
Gain weight
Nutrients are absorbed in what portion of the digestive tract?
Small intestine [duodenum]
Proteins are necessary for _________ balance
Positive protein and nitrogen balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal
, 4 kcal
1 gram of fat = ____ kcal
9 kcal
Most calorie dense
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency
< 10%
1 gram of protein = ___ kcal
4 kcal
Which amino acids are NOT manufactured by the body and MUST be obtained through diet or external
source are known as?
Indispensable amino acids
Which amino acids ARE manufactured by the body?
Dispensable amino acids
The ChooseMyPlate program was developed by whom?
U.S. Department of Agriculture
Which program established guidelines for balancing calories?
ChooseMyPlate
What are the goals of ChooseMyPlate?
decreasing portion size, increasing healthy food intake, increase water consumption, maintain body
weight in a healthy range, increase activity, decrease salt intake, increase fruit, vegetable, and whole
grain intake
Which measurement is determined by dividing the patients weight in kilograms by height in meters
squared and is considered to be the most reliable indicator of nutritional status and health by HCP's?
Body Mass Index [BMI]
Vegans are at risk for which nutritional deficiency?
Vitamin B12 deficiency b/c the vitamin is only found in animal sources and vegans ONLY consume plant
products
Breast milk or formula provides sufficient nutrition for the first _____ to _____ months of life
4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections; easier digestion;
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