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RNSG 1105 Mastery Checkoff Questions With Complete Solutions
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RNSG 1105 Mastery Checkoff Questions With Complete Solutions
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RNSG 1105 Mastery Checkoff Questions With CompleteSolutions
Administering Oxygen by a Mask Correct Answer 1. Attach
face mask to oxygen source with humidification, if needed. Start
the flow of oxygen at the specified rate. For a mask with a
reservoir, allow oxygen to fill the bag.
2. Position face mask over the patient's nose and mouth. Adjust
the elastic strap to fit snugly but comfortably on the face. Adjust
the flow rate as ordered.
3. Reassess respiratory rate, effort, and lung sounds. Note any
signs of respiratory distress, such as tachypnea, nasal flaring, use
of accessory muscles, or dyspnea.
4. Remove the mask and dry the skin every 2 to 3 hours if the
oxygen is running continuously. Do not use powder around the
mask.
5. Document as directed or per facility policy.
Administering Oxygen by a Mask: Equipment Needed Correct
Answer Flow meter, humidifier with sterile distilled water,
nasal cannula and tubing
Administering Oxygen by Nasal Cannula Correct Answer 1.
Connect nasal cannula to oxygen setup with humidification, if
needed. Adjust flow rate as ordered. Check that oxygen is
flowing out of prongs.
2. Place prongs in patient's nostrils. Place tubing over and
behind each ear with adjuster comfortably under chin. Ensure
protection pad on tubing in place over ear.
3. Tubing should be snug but not tight against the skin. Adjust as
necessary.
,4. Encourage patient to breathe through the nose, with the mouth
closed.
5. Reassess respiratory rate, effort, and lung sounds. Note any
signs of respiratory distress, such as tachypnea, nasal flaring, use
of accessory muscles, or dyspnea.
6. Document as directed or per facility policy.
Administering Oxygen by Nasal Cannula: Equipment Needed
Correct Answer Flow meter, humidifier with sterile distilled
water, nasal cannula and tubing
Administrating a Low Volume or Retention Enema Correct
Answer 1. Position the patient on the left side (Sims' position),
as dictated by patient comfort, ability and condition. Fold top
linen back just enough to allow access to the patient's rectal
area. Place a waterproof pad under the patient's hip.
2. Put on non- sterile gloves
3. Remove the cap and add generously lubricate to the end of
rectal tube 2" to 3".
4. Lift buttock to expose anus. Slowly and gently insert the
enema tube 3" to 4" for an adult. Direct it at an angle pointing
toward the umbilicus, not bladder. Ask patient to take several
deep breaths during insertion.
5. Compress the container slowly with your hands. Roll the end
up on itself, toward the rectal tip. Administer all the solution in
the container.
6. If resistance is met while inserting tube, permit a small
amount of solution to enter, withdraw tube slightly, and then
continue to insert it. Do not force entry of the tube. Ask patient
to take several deep breaths and relax.
,7. After solution has been given, remove tube, keeping the
container compressed. Have paper towel ready to receive tube as
it is withdrawn.
8. Encourage the patient to hold the solution until the urge to
defecate is strong, usually in about 5 to 15 minutes.
9. Implement safety exit measure and instruct patient to use call
light wen patient has a strong urge to defecate.
10. When patient calls with a strong urge to defecate, place him
or her in a sitting position on a bedpan or assist to commode or
bathroom. Stay with patient or have call light readily accessible.
11. Remind patient not to flush commode (if uses bathroom)
before nurse inspects results of enema.
12. Prior to flushing results assess color, consistency, amount,
and odor of feces. Wash hands with soap and water.
13. Put on gloves and assist patient if necessary with cleaning of
anal area. Offer washcloths, soap, and water for
Administrating a Low Volume or Retention Enema Correct
Answer Low volume enema bottle (oil retention enema, fleets
enema), water-soluble lubricant, bedpan, bedside commode, or
nearby bathroom ready for use with tissue paper, waterproof
pad, basin, wash cloth, towels and soap, and non- sterile gloves.
Administration of High Volume or Cleansing Enema Correct
Answer 1. Open package, clamp is tubing then open top of bag
and fill bag with warm water.
2. Release clamp and allow fluid to progress through tube until
air is removed and water is to the end. Reclamp tubing.
3. Position the patient on the left side in side lying or Sim's
position. Fold top linen back just enough to allow access to the
patient's rectal area. Place a waterproof pad under hip.
, 4. Put on non-sterile gloves.
5. Elevate solution so that it is no higher than 18 inches above
level of anus. Plan to give the solution slowly over a period of 5
to 10 minutes. The container may be hung on an IV pole or held
in the nurse's hands at the proper height.
6. Generously lubricate end of rectal tube 2 to 3 inches. A
disposable enema set may have a pre-lubricated rectal tube.
7. Lift buttock to expose anus. Slowly and gently insert the
enema tube 3 to 4 inches for an adult. Direct it at an angle
pointing toward the umbilicus, not bladder. Ask patient to take
several deep breaths.
8. If resistance is met while inserting tube, permit a small
amount of solution to enter, withdraw tube slightly, and then
continue to insert it. Do not force entry of the tube.
9. Introduce warm solution slowly over a period of 5 to 10
minutes. Hold tubing all the time that solution is being instilled.
10. Clamp tubing or lower container if patient has desire to
defecate or cramping occurs. Patient also may be instructed to
take small, fast breaths or to pant.
11. After solution has been given, clamp tubing and remove
tube. Have paper towel or towel ready to receive tube as it is
withdrawn.
12. Encourage the patient to hold the solution as long as
possible. Once the urge to defecate is strong, usually
immediately with high volume enema, assist patient on bedpan
and off bedpan when finished eliminating solution. Bring
bedpan to bathroom.
13. Prior to f
Administration of High Volume or Cleansing Enema Correct
Answer Disposable enema set, water-soluble lubricant, IV pole,
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