Elimination Study Guide Q&A

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What abnormal characteristics should you report after obtaining a urine sample? (Select all that apply.)
a. Moderate amount of sediment
b. Cloudiness of urine
c. Light amber color
d. Slight musty odor
e. Yellow color
f. Blood tinged

a. Moderate amount of sediment
b. Cloudiness of urine
f. Blood tinged

Which of the following are normal characteristics of urine? (Select all that apply.)
a. pH 4.6 to 8
b. Red blood cell count greater than 2
c. Specific gravity 1.010 to 1.025
d. Protein absent
e. Casts present
f. White blood cells 0 to 4

a. pH 4.6 to 8
c. Specific gravity 1.010 to 1.025
d. Protein absent
f. White blood cells 0 to 4

What factors are necessary to determine whether a patient can be instructed to independently obtain a midstream urine specimen? (Select all that apply.)
a. If the patient is able to use toilet facilities independently
b. If the patient is able to comprehend instructions
c. If the patient is a non-toilet-trained child
d. If the patient would be embarrassed easily

a. If the patient is able to use toilet facilities independently
b. If the patient is able to comprehend instructions

The nurse has delegated the task of obtaining a mid-stream urine specimen to the NAP. Which of the following responsibilities does not remain with the nurse who delegated the task?
a. Understanding the results and reporting them to the physician.
b. Determining who is capable and knowledgeable to carry out the task with accuracy.
c. Ensuring the task was completed and performed accurately.
d. Instructing the patient on the procedure to gain cooperation.

d. Instructing the patient on the procedure to gain cooperation.

The nurse has instructed a patient regarding the procedure for obtaining a midstream urine specimen. The patient asks, "Why does the urine sample need to be collected in this manner?" The nurse's best response is:
a. "The initial stream flushes out resident microorganisms that accumulate at the urethral meatus."
b. "It is performed this way to in order to verify that fresh urine is obtained for testing."
c. "This method will prevent you from developing urinary incontinence."
d. "By waiting to catch the middle of the urine stream, it provides time to ensure that the bladder will empty completely."

a. "The initial stream flushes out resident microorganisms that accumulate at the urethral meatus."

The nurse has instructed the male patient about how to properly clean himself in preparation for obtaining a midstream urine specimen. Which statement made by the patient indicates correct understanding?
a. "I should clean in a direction from the most contaminated area to the least contaminated area."
b. "I should begin cleaning at the opening (meatus) and going outward in a circular motion."
c. "I should wash the area well with soap and water, and then I am ready to provide the specimen."
d. "I should clean in a direction from front to back."

b. "I should begin cleaning at the opening (meatus) and going outward in a circular motion."

The NAP is obtaining a midstream urine specimen from a female patient. Which action, if made by the NAP, requires correction and indicates that further instruction is needed?
a. The NAP cleans the patient using a new swab for each cleansing.
b. The NAP cleans the patient in a front -to-back motion.
c. The NAP cleans the patient starting at the center and then uses the same swab to clean the sides.
d. The NAP cleans in a direction going from the least contaminated to the most contaminated area.

c. The NAP cleans the patient starting at the center and then uses the same swab to clean the sides.

How much urine is needed to do a urine culture?
a. At least 3 mL
b. At least 20 mL
c. At least 1 L
d. 30 to 60 mL

a. At least 3 mL

How much urine is needed to do a routine urinalysis?
a. At least 3 mL
b. At least 20 mL
c. At least 1 L
d. 30 to 60 mL

b. At least 20 mL

The presence of ketones in the urine may be seen with ___________________.

dehydration, starvation, and poorly controlled diabetes.

The presence of glucose in the urine is found with ______ diabetic control.

poor

Protein in the urine suggests ______________________.

renal disease or damage.

________________ occurs with kidney disease or damage, trauma, and surgery.

Hematuria (red blood cell counts greater than 2)

An elevated white blood cell count ( greater than 4) and the presence of bacteria occur with _________.

UTI.

The nurse is performing a Hemoccult test on stool of a patient with a low hemoglobin and hematocrit. Which one of the following steps would be inaccurate and would require correction?
a. Perform hand hygiene and apply clean gloves. Use the tip of a wooden applicator to obtain small portion of feces. Apply this smear of stool onto paper in the first box.
b. Obtain a second fecal specimen from a different area of stool, and apply a thin smear to the second box of slide.
c. Close the slide cover, turn the slide over, open the cardboard flap, and apply one drop of Hemoccult developing solution to each box.
d. Read the results after 30 to 60 seconds. Dispose of the gloves and the test slide. Perform hand hygiene.

c. Close the slide cover, turn the slide over, open the cardboard flap, and apply one drop of Hemoccult developing solution to each box.

The nurse is instructing the NAP about how to perform a Hemoccult test. Which statement, if made by the NAP, indicates that further teaching is necessary and would require correction?
a. "When preparing the Hemoccult slide, I should moisten the windows of the testing slide before applying the fecal sample."
b. "Blue discoloration indicates the presence of blood in the stool."
c. "I should wear nonsterile, clean gloves during stool testing."
d. "The stool sample is applied to each of the two little boxes on the inside of the Hemoccult slide."

a. "When preparing the Hemoccult slide, I should moisten the windows of the testing slide before applying the fecal sample."

The nurse is going to perform a Hematest on a fecal sample. Which of the following would be an incorrect action if made by the nurse?
a. The Hematest tablets are placed on the guaiac paper, and the stool sample is placed on top of the Hematest tablet.
b. The Hematest tablets are protected from light and moisture.
c. Testing the stool for blood using a Hematest can be delegated to an NAP.
d. Water applied to the Hematest tablets should be allowed to flow onto the guaiac paper.

a. The Hematest tablets are placed on the guaiac paper, and the stool sample is placed on top of the Hematest tablet.

The nurse wants to assess the patient for factors that may place the patient at risk for gastrointestinal bleeding. Which of the following would increase the patient's potential for having a positive Hemoccult test? (Select all that apply.)
a. Anticoagulants (e.g., Lovenox, Heparin, Coumadin)
b. Long-term use of steroids
c. Having a recent blood transfusion
d. Long term use of nonsteroidal antiinflammatory drugs (NSAIDs)
e. Antidiabetic agents (oral hypoglycemics)
f. Acetylsalicylic acid (aspirin)

a. Anticoagulants (e.g., Lovenox, Heparin, Coumadin)
b. Long-term use of steroids
c. Having a recent blood transfusion
d. Long term use of nonsteroidal antiinflammatory drugs (NSAIDs)
f. Acetylsalicylic acid (aspirin)

5. The patient had a positive Hemoccult test. Which of the following could affect the test result? (Select all that apply.)
a. Povidone-iodine
b. Ascorbic acid (vitamin C)
c. Beer or wine
d. Antibiotics
e. Diets rich in carbohydrates

a. Povidone-iodine
b. Ascorbic acid (vitamin C)
c. Beer or wine

The NAP reports that the Hemoccult test was positive. This means that:
a. The patient has colon cancer.
b. No further testing is required.
c. There is an absence of GI bleeding.
d. The test result turned blue.

d. The test result turned blue.

The patient is reading some literature about screening for colon cancer. The patient asks, "What is melena?" The nurse is correct to respond:
a. "Noticeable bright-red blood in the stool, typically from hemorrhoids."
b. "Black tarry feces caused by the digestion of blood in the GI tract."
c. "When fat is not digested well and causes a white or clay-colored foul-smelling frothy stool."
d. "Pain with defecation, usually due to the presence of polyps."

b. "Black tarry feces caused by the digestion of blood in the GI tract."

What is the primary function of the colon?

Absorbs, protects, secretes, eliminates

What is the primary function of the rectum?

Temporarily stores feces until elimination

What is the primary function of the small intestine?

Receives enzymes from the gallbladder and pancreas to further break down chyme; absorbs nutrients

What is the primary function of the esophagus?

Where peristalsis moves food to stomach

What is the primary function of the stomach?

Secretes hydrochloric acid and pepsin; converts bolus of food to chime

If a patient had to have part of their colon (large intestine) removed, which of the following may result?
a. The patient could experience an acid-base imbalance.
b. The patient could experience increased amounts of mucus in the stool.
c. The patient could experience fluid volume overload with increased absorption.
d. Once healed, it would be unlikely for the patient to experience any alteration in elimination.

a. The patient could experience an acid-base 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.)
a. The patient is 81 years old.
b. The patient reports rare laxative use.
c. The patient takes narcotics for chronic back pain.
d. The patient eats whole grains; raw fruits; and green, leafy vegetables.
e. The patient takes daily iron and calcium supplements.
f. The patient reports daily exercise and remains active.

a. The patient is 81 years old.
c. The patient takes narcotics for chronic back pain.
e. The patient takes daily iron and calcium supplements.

The student nurse is studying the order of the GI tract in preparation for an anatomy examination. Which of the following indicates correct understanding?
a. mouth, esophagus, stomach, colon, small intestine, anus
b. ascending colon, transverse colon, descending colon, sigmoid colon
c. stomach, duodenum, ileum, jejunum, cecum, large intestine, rectum
d. cecum, small intestine, descending colon, transverse colon, ascending colon

b. ascending colon, transverse colon, descending colon, sigmoid colon

An increase in venous pressure caused by liver disease can result in the development of:
a. Hemorrhoids
b. Flatulence
c. Impaction
d. Diarrhea

a. Hemorrhoids

The comatose patient in an intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of diarrheal stool. What should the nurse suspect?
a. Diarrhea as a result of decreased muscle tone
b. Impaction
c. A vagal response
d. Flatulence

b. Impaction

The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient would have a vagal response, what would the nurse most likely observe?
a. Tachycardia
b. Hypertension
c. A decrease in heart rate
d. A decrease in respirations

c. A decrease in heart rate

A 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:
a. At least 2000 mL of tap water
b. 1000 mL or less of tap water
c. 5 mL of castile soap and 1500 mL of water
d. 180 mL of prepackaged (Fleets) enema solution

b. 1000 mL or less of tap water

The physician has ordered a Fleets enema for a patient experiencing constipation. Which of the following actions would require correction?
a. The nurse delegates the task to an NAP.
b. The nurse removes the protective cap from the rectal tip.
c. The nurse squeezes and releases the bottle several times until all of the solution has entered the patient.
d. The nurse administers the enema at room temperature or, if too cool, warms the solution by holding the bottle under warm running water.

c. The nurse squeezes and releases the bottle several times until all of the solution has entered the patient.

A patient complains of cramping during the administration of an enema. What could be a possible cause? (Select all that apply.)
a. A too rapid instillation of the solution
b. Patient placed in the Sims' position
c. Holding the enema bag too low during the infusion
d. Cold enema solution

a. A too rapid instillation of the solution
d. Cold enema solution

Which of the following could signal a rectal perforation?
a. Inability to hold the enema solution
b. A rigid and painful abdomen
c. Dilated purplish-red protrusions at the anus
d. A decrease in heart rate and an increase in blood pressure

b. A rigid and painful abdomen

Which of the following is the best example of documentation of enema administration?
a. 0800 1000mL tap water enema administered without difficulty. Moderate return of soft-formed brown stool.
b. 1000 soap suds enema administered. Patient tolerated well.
c. 0830 800 mL tap water enema administered. Return clear with no fecal material bowel sounds present in all 4 quadrants pre- and postprocedure. Abdomen nondistended. Patient states "I'm glad that's over."
d. 0900 1000 mL warmed tap water with 5 mL castile soap enema administered per doctor's order. Patient instructed not to flush toilet. Patient held enema solution approximately 5 minutes. Good return. Patient repositioned for comfort. Call light in reach.

c. 0830 800 mL tap water enema administered. Return clear with no fecal material bowel sounds present in all 4 quadrants pre- and postprocedure. Abdomen nondistended. Patient states "I'm glad that's over."

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?
a. The NAP holds the enema container approximately 12 inches above the level of the patient's anus.
b. The NAP places the patient in a left side-lying position with the right knee flexed.
c. The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it.
d. After filling the enema bag with warmed solution, the NAP raises the container, releases the clamp and allows solution to flow to fill tubing.

c. The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it.

A patient is to receive enemas "until clear." You note that stool remains in the fecal return after the second enema. What should you do?
a. Notify the physician.
b. Stop, because too many large-volume enemas can cause a fluid and electrolyte imbalance.
c. Administer a third enema.
d. Add castile soap to the next enema solution.

c. Administer a third enema.
Rationale: You should administer a third enema. If you continue to see fecal matter in the third return, you should notify the physician, because too many large-volume enemas can cause a serious fluid and electrolyte imbalance.

A patient is diagnosed with colorectal cancer. Which type of ostomy is the patient most likely to have after surgery?
a. Loop
b. End
c. Double barrel
d. Kock pouch

b. End

A patient has a double-barrel colostomy. The patient complains that the distal stoma is "wet." What is your best response?
a. "The distal stoma may secrete mucus, and that would be normal."
b. "The distal stoma of a double-barrel colostomy is the functional end that excretes urine and requires more frequent changing of the pouch."
c. "The proximal stoma secretes mucus but otherwise is considered nonfunctional. The output from the distal stoma is called effluent."
d. "Let me take a look at your pouch of the distal stoma; perhaps it is leaking."

a. "The distal stoma may secrete mucus, and that would be normal."

What type of colostomy construction is described here? Bowel surgically severed, and the two ends brought out onto the abdomen.

Double barrel colostomy

What type of colostomy construction is described here? Two openings through one stoma; proximal end drains stool and distal portion drains mucus.

Loop colostomy

What type of colostomy construction is described here? One stoma formed from proximal end of bowel with distal portion of GI tract either removed or sewn closed.

End colostomy

A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response?
a. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?"
b. "You sound like you are in disbelief. Why do you feel this way?"
c. "Don't worry. Many patients have had this same surgery and learn to manage very well."
d. "How has your husband reacted to the news?"

a. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?"

You are pouching an enterostomy. What steps should you take?

Always perform hand hygiene first, then auscultate for bowel sounds, assess the skin barrier and pouch for leakage, and position the patient comfortably. Repeat hand
hygiene, apply clean gloves, and place a waterproof pad under the patient. Next, you should gently clean the skin. You should measure the stoma and cut the opening on the pouch one-sixteenth larger than the stoma before removing the backing. Use sealant wipes, and allow the skin to dry before applying the adhesive backing of the pouch. Then snap on the pouch. Apply nonallergenic tape around the pectin skin barrier, apply the ostomy belt, and cleanse the area. Remove gloves and perform hand hygiene. Document the procedure.

2. The best time to change the skin barrier pouch is:
a. After breakfast
b. After lunch
c. After dinner
d. Several hours after breakfast
e. Several hours after lunch

d. Several hours after breakfast
e. Several hours after lunch

Identify the equipment you will need to pouch an enterostomy by using a precut system.
a. Basin with warm tap water
b. Gauze pads or washcloth
c. Towel or disposable waterproof barrier
d. Sterile gloves
e. Pouch closure device, such as a clamp
f. Clean disposable gloves
g. Pouch: clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type with attached skin barrier
h. Skin barrier, such as sealant wipes or wafer
i. Nonallergenic tape or ostomy belt
j. Skin barrier paste or stoma adhesive, if needed

a. Basin with warm tap water
b. Gauze pads or washcloth
c. Towel or disposable waterproof barrier
e. Pouch closure device, such as a clamp
f. Clean disposable gloves
g. Pouch: clear drainable colostomy/ileostomy in correct size for two-piece system or a one-piece type with attached skin barrier
h. Skin barrier, such as sealant wipes or wafer
i. Nonallergenic tape or ostomy belt
j. Skin barrier paste or stoma adhesive, if needed

Identify interventions for irritation around the stoma.
a. Make sure there is a good seal of the skin barrier and/or pouching system so that undermining of fecal contents will be avoided.
b. Remove the pouch more quickly.
c. Determine whether the patient is having an allergic reaction, such as an allergic reaction to the tape.
d. Remeasure the stoma size and check whether the selected pouch is correct for the patient's stoma size.
e. Determine whether a convex disk, skin barrier paste, or other measures are needed to prevent leakage.
f. Avoid the use of a skin barrier for subsequent pouch changes.

a. Make sure there is a good seal of the skin barrier and/or pouching system so that undermining of fecal contents will be avoided.
c. Determine whether the patient is having an allergic reaction, such as an allergic reaction to the tape.
d. Remeasure the stoma size and check whether the selected pouch is correct for the patient's stoma size.
e. Determine whether a convex disk, skin barrier paste, or other measures are needed to prevent leakage.

The NAP reports to you that your 50-year-old patient's stoma appears purple. What might you suspect?
a. There is a lack of circulation to the stoma.
b. The patient ate something purple colored.
c. The patient has been exercising vigorously.
d. Nothing, this is a normal finding.

a. There is a lack of circulation to the stoma.

The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates that further instruction is needed?
a. "As long as it isn't leaking, the skin barrier can remain in place for a week."
b. "I should clean the peristomal skin with soap and warm water."
c. "I should apply barrier paste to fill in the crease and allow it to dry 1 to 2 minutes."
d. "I should only use adhesive remover when necessary and wash the area afterwards."

b. "I should clean the peristomal skin with soap and warm water."

As people age, ________, which leads to the possibility of constipation.

peristalsis slows

________ infection may result in a duodenal ulcer.

H. pylori

Vomiting and diarrhea can result in _______________________.

fluid volume loss and dehydration

Physical activity promotes __________________, reducing the likelihood of constipation.

peristalsis and strengthens muscles

Hemorrhoids may cause ____________________.

pain, itching, and burning sensations

_______ may result in slowed peristalsis caused by hormonal changes with resultant constipation.

Pregnancy

_______________ may cause constipation or diarrhea.

Medications and preparations for diagnostic testing

Anxiety may induce _______.

diarrhea

Depression may lead to _________.

constipation

What type of diversion is described here? This has two openings through the one stoma. The proximal end drains stool and the distal portion drains mucus.

Loop colostomy

What type of diversion is described here? This is a continent colostomy.

Sigmoid colostomy

What type of diversion is described here? The bowel is surgically severed, and the two ends are brought out onto the abdomen.

Double-barrel colostomy

What type of diversion is described here? One stoma is formed from the proximal end of the bowel with the distal portion of the GI tract either removed or sewn closed.

End colostomy

What type of diversion is described here? This is incontinent and bypasses the entire large intestine.

ileostomy

What type of diversion is described here? This is an incontinent colostomy with semi-formed stool.

Transverse colostomy

What type of diversion is described here? This is incontinent, and one or both ureters are brought to the abdominal surface.

Ureterostomy

From the following, choose the four primary functions of the colon:
a. Absorption
b. Protection
c. Transference
d. Storage
e. Release
f. Secretion
g. Elimination
h. Reuptake

a. Absorption
b. Protection
f. Secretion
g. Elimination

From the following, choose the correct equipment to bring to the bedside in order to administer the commercially prepared Fleet enema.
a. Commercially prepared enema product
b. Waterproof bed pad
c. Bedside commode
d. Tubing with a rectal tip
e. Enema bag
f. Castile soap
g. Water-soluble lubricant
h. Sterile gloves
i. Toilet paper and/or basin with warm water, washcloth, and towel
j. Clean disposable gloves

a. Commercially prepared enema product
b. Waterproof bed pad
c. Bedside commode
g. Water-soluble lubricant
i. Toilet paper and/or basin with warm water, washcloth, and towel
j. Clean disposable gloves

Which of the following would be inappropriate to delegate to an NAP?
a. Administering a Fleet-type (i.e., commercially prepared) enema
b. Pouching a newly established ostomy
c. Recording the amount of ostomy output
d. Administering a tap water enema

b. Pouching a newly established ostomy

What type of enema is described here?
Hypotonic; risk of circulatory overload

Tap water enema

What type of enema is described here? Safest solution to use; only type to use with infants with children

Normal saline

What type of enema is described here? Hypertonic; contraindicated in dehydrated patients; good for patients who are unable to tolerate large volumes of fluid

Commercially prepared Fleet enema

What type of enema is described here? Creates the effect of intestinal irritation to stimulate peristalsis

Soap suds

What type of enema is described here? Patient should retain several hours, if possible, to soften feces

Oil retention

What type of enema is described here? Provides relief from gaseous distention

Carminative (e.g., MGW)

What type of enema is described here? Contains drugs for a therapeutic effect

Medicated enemas

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. "The presence of bowel sounds indicates the presence of peristalsis."
b. "I am listening to make sure that you need the enema."
c. "I am listening to determine which position I should place you in for the administration of the enema."
d. "The presence of bowel sounds indicates you will be able to hold the solution."

a. "The presence of bowel sounds indicates the presence of peristalsis."

Which of the following patients would it be considered acceptable to administer an enema, and the nurse would not need to question the order?
a. A patient with glaucoma
b. A patient who is going to have surgery
c. A patient with inflammatory bowel disease
d. A patient with increased intracranial pressure

b. A patient who is going to have surgery

A nurse is preparing to administer an enema. Which of the following actions indicates correct understanding?
a. The nurse administers a normal saline enema without a physician's order when the patient has not had a bowel movement after 3 days
b. The nurse adds 5 mL of castile soap to the enema bag and then fills it to the prescribed level with water.
c. The nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation.
d. The nurse places the male patient in the dorsal recumbent position for enema administration.

c. The nurse holds the tubing in the patient's rectum constantly until the end of fluid instillation.

The nurse is reviewing with the NAP enema administration. Which of the following statements indicates further instruction is necessary?
a. "The rectal tube of an enema should be inserted 7.5 to 10 cm (3 to 4 inches) into the rectum of an adult."
b. "The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of an adolescent."
c. "The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of a child."
d. "The rectal tube of an enema should be inserted 2.5 to 3.75 cm (1 to 1 ½ inches) into the rectum of an infant."

b. "The rectal tube of an enema should be inserted 5 to 7.5 cm (2 to 3 inches) into the rectum of an adolescent."

11. Which of the following would be considered a normal finding after the administration and evacuation of an enema?
a. The patient passes approximately 50 mL of bright-red blood.
b. The patient complains of a firm and painful abdomen.
c. High-pitched, hyperactive bowel sounds are present.
d. Abdominal distention is absent.

d. Abdominal distention is absent.

The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse?
a. Stop the instillation and remove the tube from the rectum.
b. Have the patient take deep breaths in and out through the nose.
c. Raise the height of the enema container.
d. Lower the height of the enema container.

d. Lower the height of the enema container.

Which of the following is considered a sterile procedure and, therefore, requires sterile gloves?
a. Pouching an ostomy
b. Administering a cleansing enema
c. Preparing a soapsuds enema for administration
d. None of the above

d. None of the above

The nurse understands the important role in helping the patient with an ostomy accept the change in self-image. Which of the following indicates that 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. The patient is willing to look at the stoma.
c. The patient is asking many questions.
d. The patient holds a gauze pad over the stoma while cleaning the peristomal skin.

a. The patient continues to rely on the nurse to change the ostomy pouch.

How often should an ostomy pouch be changed?
a. 3 to 7 days
b. 7 to 10 days
c. Daily
d. Every other day
e. Every 2 weeks

a. 3 to 7 days

The nurse is pouching an ostomy. The patient asks why the nurse always measures the size of the stoma stating, "Don't you remember how large to cut the opening?" Which of the following would be an inaccurate response by the nurse and would require correction?
a. "Too large an opening will permit fecal drainage to ooze from under the appliance and would cause skin irritation."
b. "Too small an opening causes the appliance to cut into the stoma."
c. "The stoma will shrink and reach usual stoma size in 6 to 8 weeks."
d. "The stoma typically increases in size with the passage of time."

d. "The stoma typically increases in size with the passage of time."

The NAP tells the nurse that she does not want to care for a certain patient, because she is afraid of contracting C. difficile. Which response by the nurse is best?
a. "Good hand hygiene is your best defense against C. difficile."
b. "C. difficile can only be acquired through antibiotic therapy, chemotherapy, or invasive bowel procedures."
c. "C. difficile is the organism responsible for duodenal ulcers."
d. "I can reassign you to care for a different patient."

a. "Good hand hygiene is your best defense against C. difficile."

The nurse instructs the patient that his physician has ordered that he receive an enema. The patient states, "An enema! I'm not constipated." What are other possible reasons for the order? (Select all that apply.)
a. Bowel retraining
b. Preparation for a diagnostic procedure
c. Preparation for surgery
d. Administration of a medication
e. Prevention of laxative misuse

a. Bowel retraining
b. Preparation for a diagnostic procedure
c. Preparation for surgery
d. Administration of a medication

An intervention that is directly related to patient safety that must be considered when providing an elderly patient with an enema is to:
1. Assess for the presence of external hemorrhoids.
2. Provide assistance to the bathroom for expulsion of fluid.
3. Document the patient's physical response to the enema.
4. Instruct the patient to attempt to retain the fluid for 5 to 10 minutes.

2. Provide assistance to the bathroom for expulsion of fluid.

The nurse is preparing to administer an enema. To best facilitate insertion of the fluid, the nurse should:
1. Position the patient on her left side with her right knee bent.
2. Lubricate the first 3 to 4 inches of the tip of the rectal tube.
3. Instruct the patient to relax by slowly breathing out through her mouth.
4. Hold the tubing in the rectum until all fluid has been instilled successfully.

2. Lubricate the first 3 to 4 inches of the tip of the rectal tube.

The nurse is delegating a patient's enema to assistive personnel. The 79-year-old patient has mild left-sided muscle weakness resulting from a cerebral vascular accident (CVA) 2 years ago. The enema order reads, "Enemas until clear." Which of the following statements made by the assistive personnel requires follow-up by the nurse?
1. "I'll need help turning her onto her side."
2. "It may take three or four enemas to achieve a clear return."
3. "I'll test the water temperature on the inside of my own wrist."
4. "This will wear her out, so I'll wait until after she ambulates."

2. "It may take three or four enemas to achieve a clear return."

The nurse is preparing the fluid for an enema to be administered to a 72-year-old patient for complaints of constipation. The nurse appropriately:
1. Prepares 750 ml of warm solution.
2. Positions the patient on his right side.
3. Elevates the solution bag 20 to 25 inches above the bed.
4. Infuses the solution over a 4- to 7-minute period.

1. Prepares 750 ml of warm solution.

Which of the following actions best describes aseptic technique when administering an enema to an elderly patient with dementia?
1. Properly disposing of fecal-soiled linen
2. Padding the patient's bed thoroughly
3. Washing hands after removing gloves
4. Cleansing the perineum after expelling the fluid

3. Washing hands after removing gloves

Which of the following actions is most appropriate when the nurse has been unsuccessful in attempts to insert a nasogastric tube using either naris?
1. Ask another nurse to attempt the insertion.
2. Document the attempts in the patient's medical record.
3. Notify the physician that the attempts have been unsuccessful.
4. Allow the patient to rest for 30 minutes before resuming the process.

3. Notify the physician that the attempts have been unsuccessful.

Which of the following is the correct response if resistance is met while attempting to advance a nasogastric tube?
1. Ask the patient to cough.
2. Remove the nasogastric tube.
3. Encourage the patient to swallow.
4. Instruct the patient to hyperextend his or her neck.

2. Remove the nasogastric tube.

The introduction of a nasogastric tube is appropriate for which of the following postoperative patients?
1. 28-year-old patient who fractured a femur after ingesting a large quantity of alcohol
2. 73-year-old patient who experienced a pulmonary embolus 3 months ago
3. 54-year-old patient who sustained a broken cheekbone in a fall
4. 67-year-old patient with a history of unexplained nosebleeds

1. 28-year-old patient who fractured a femur after ingesting a large quantity of alcohol

The nurse receives an order to insert a nasogastric tube on a patient experiencing a possible bowel obstruction. Which of the following actions should the nurse perform in preparation for the insertion in order to evaluate the effective placement of the tube?
1. Assess for bowel sounds by auscultating the abdomen.
2. Place the patient in a high-Fowler's position.
3. Assess the airway through the nasal passages.
4. Instruct the patient to blow his or her nose.

1. Assess for bowel sounds by auscultating the abdomen.

Which of the following interventions can the nurse delegate to ancillary staff regarding the insertion of a nasogastric tube in a elderly patient?
1. Positioning the patient in a high-Fowler's position
2. Assessing the patient's abdomen for bowel sounds
3. Determining any history of unexplained nosebleeds
4. Educating the patient regarding the need for the intervention

1. Positioning the patient in a high-Fowler's position

The initial step in the preparation of a fecal occult blood test is to:
1. Determine the patient's ability to assist with securing the sample.
2. Gather both a Hemoccult slide and developing solution.
3. Provide the patient with a specimen "hat" or bedpan.
4. Perform hand hygiene and don treatment gloves.

1. Determine the patient's ability to assist with securing the sample.

The nurse has delegated the task of performing fecal occult blood tests on the stool of a patient with a history of positive results to ancillary staff. Which of the following instructions is most relevant to the performance of this testing for this particular patient?
1. "Notify me immediately if the test is positive."
2. "Remember to re-test each positive stool sample."
3. "Remind the patient that we need to test each bowel movement."
4. "Don't confuse Gastroccult developer with Hemoccult developer.

2. "Remember to re-test each positive stool sample."

Which of the following statements made by a nurse providing information to unlicensed ancillary staff is most relevant to the proper performance of a fecal occult blood test on the stool of a patient with a low hemoglobin and hematocrit?
1. "Have you used the new Hemoccult testing system?"
2. "Re-enforce the need to use the "hat" with the patient."
3. "Is the patient capable of assisting with the collection?"
4. "Remember to take samples from two different areas of the specimen."

1. "Have you used the new Hemoccult testing system?"

Which of the following statements shows an understanding of the proper interpretation of the results of a positive fecal occult blood test?
1. "If the sample turns blue, it is positive for blood."
2. "The sample turned blue after about 45 seconds."
3. "The results were positive both times I tested the sample."
4. "Because it was positive, I asked when he last ate red meat."

4. "Because it was positive, I asked when he last ate red meat."

Which of the following nursing actions addresses the risk for infection related to the performance of a fecal occult blood test?
1. Maintaining aseptic technique while performing the test
2. Performing the fecal occult blood testing in the patient's bathroom
3. Ensuring appropriate hand hygiene and donning treatment gloves while testing
4. Assessing the patient's ability to provide an uncontaminated fecal specimen

3. Ensuring appropriate hand hygiene and donning treatment gloves while testing

The initial action when preparing to change the pouching system of a patient's colostomy is to:
1. Don clean treatment gloves.
2. Drape the patient appropriately.
3. Position the patient on the toilet if possible.
4. Assess the surrounding skin for signs of irritation.

1. Don clean treatment gloves.

When pouching a patient's colostomy, which of the following nursing goals is directly related to the patient's risk for injury?
1. Collecting all fecal drainage from the colostomy
2. Maintaining the patient's fecal elimination function
3. Promoting patient autonomy with fecal elimination care
4. Protecting the skin from irritation caused by fecal drainage

4. Protecting the skin from irritation caused by fecal drainage

In order to best minimize the risk of injury to the skin surrounding the stoma when changing the pouching system, which of the following actions should be considered routinely?
1. Minimize the use of adhesive remover.
2. Replace the ostomy belt snuggly but not too tightly.
3. Avoid unnecessary changes of the pouching system.
4. Always wear clean treatment gloves during the procedure.

3. Avoid unnecessary changes of the pouching system.

When initially preparing to educate the patient concerning self-care of a colostomy pouching system, the nurse should:
1. Arrange for a capable family member to be present during the initial demonstration.
2. Evaluate the patient's vision and dexterity to best determine the type of system to use.
3. Collect written information to present to the patient as supplemental instructional materials.
4. Assess the patient's emotional readiness and physical ability to provide autonomous care.

4. Assess the patient's emotional readiness and physical ability to provide autonomous care.

Which of the following statements provides the best guideline for instructing unlicensed ancillary staff regarding the care of a patient with a colostomy?
1. "Be sure to pat dry the skin surrounding the stoma before applying the new pouch."
2. "Alert me immediately if you see any blood in the fecal matter that is collected in the pouch."
3. "Using the stoma guide, cut the pouch opening about 1/8 of an inch bigger than the stoma."
4. "Remember to change your treatment gloves after cleansing the stoma and surrounding skin."

2. "Alert me immediately if you see any blood in the fecal matter that is collected in the pouch."

The initial action when preparing to change the pouching system of a patient's ureterostomy is to:
1. Don clean treatment gloves.
2. Drape the patient appropriately.
3. Position absorbent padding beneath the patient.
4. Determine when the current pouch was applied.

4. Determine when the current pouch was applied.

When pouching a patient's ureterostomy, which of the following nursing goals is directly related to the patient's risk for injury?
1. Collecting all urinary drainage from the ureterostomy
2. Maintaining the patient's urinary elimination function
3. Promoting patient autonomy with urinary elimination care
4. Protecting the skin from irritation caused by urinary drainage

4. Protecting the skin from irritation caused by urinary drainage

In order to best minimize the risk of infection when changing the pouching system of a patient with an ureterostomy with stents, which of the following actions should be considered routinely?
1. Perform the procedure wearing sterile gloves.
2. Fill skin creases around the stoma with barrier paste.
3. Avoid accidental dislodgement of the ureteral stents.
4. Use rolled gauze wicks to collect trickling urine.

1. Perform the procedure wearing sterile gloves.

When initially preparing to educate the patient concerning self-care of a ureterostomy pouching system, the nurse should:
1. Arrange for a capable family member to be present during the initial demonstration.
2. Evaluate the patient's vision and dexterity to best determine the type of system to use.
3. Collect written information to present to the patient as supplemental instructional materials.
4. Assess the patient's emotional readiness and physical ability to provide autonomous care.

4. Assess the patient's emotional readiness and physical ability to provide autonomous care.

Which of the following statements provides the best guideline for instructing unlicensed ancillary staff regarding the care of a patient with a newly formed ureterostomy?
1. "Be sure to pat dry the skin surrounding the stoma before applying the new pouch."
2. "Alert me immediately if you see any blood in the urine that is collected in the pouch."
3. "Using the stoma guide, cut the pouch opening about 1/8 of an inch bigger than the stoma."
4. "Remember to use warm water when cleansing the stoma and surrounding skin."

2. "Alert me immediately if you see any blood in the urine that is collected in the pouch."

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