Enema PDF

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WEEK 11 REVIEW QUESTIONS NUTRITION AND ENEMA 1. What snack choice would be the best suggestion by the nurse for a patient on a renal diet? a. Peanut butter b. Bananas c. Diet cola d. Carrot sticks 2. A patient recovering from major abdominal surgery is to progress from a clear liquid diet to the next diet level. Which statement by the nurse would be most appropriate in this circumstance? a. “You will progress from a clear liquid diet to a mechanical soft diet.” b. “If you can tolerate the clear liquid diet, your next meal will be a full liquid.” c. “You will receive a regular diet tray with anything you want at the next meal.” d. “It is important that you eat a pureed diet after you are able to tolerate the clear liquids.” 3. What nursing intervention would be most beneficial to implement in an effort to prevent aspiration by a patient receiving tube feedings? a. Check the pH of stomach contents before starting each feeding. b. Hold prescribed medications until after each feeding. c. Elevate the head of the patient’s bed at least 45 degrees. d. Slow the delivery of the tube feeding to 15 mL/hour. 4. Which action should the nurse take when caring for a patient receiving a continuous enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube if the feeding tube becomes occluded? a. Use 15 mL of cranberry juice in a 30-mL syringe to clear the tubing. b. Ask to have the PEG tube replaced to prevent rupture of the gastrostomy. c. Flush the PEG tube with 60 mL of cold tap water, using gravity. d. Try using cola if a 20- to 30-mL warm-water flush is ineffective. 5. The nurse is caring for an elderly patient who has residual weakness on the right side as the result of a cerebrovascular accident (stroke). The nurse is correct in reporting dysphagia when the patient exhibits which symptom(s)? (Select all that apply.) a. Incomplete lip closure b. Presence of a normal gag reflex c. A change in voice quality after eating d. Difficulty speaking, with a slow, weak voice e. Abnormal movements of the mouth, tongue, and lips 6. A young adult female is considering becoming pregnant and is not taking any multivitamins. Which instruction would best help reduce the potential for development of neural tube defects in the fetus? a. Discuss taking selenium supplements with meals.

Review Questions b. Stress the importance of prenatal exercise. c. Recommend folic acid dietary supplements. d. Inquire about the patient’s diet and birth control method. 7. A patient tells the nurse that he needs to increase his intake of potassium because he has been taking large doses of diuretics. To minimize complications from hypokalemia, the nurse should instruct the patient to include which foods as a part of his diet? a. Cheese and crackers b. Peanut butter and jelly sandwich c. Tomatoes and spinach d. Apples and grapes 8. A Jewish patient who adheres to a kosher diet is diagnosed with type 1 diabetes. What would be the best response of the nurse when the patient refuses to take insulin, stating, “Insulin contains pork and I do not eat pork”? a. “There is only a tiny amount of pork by-product in insulin.” b. “All of the insulin used today is made synthetically.” c. “I will notify your physician to change the insulin order.” d. “You really do not have the option of not taking insulin.” 9. A female Muslim patient is admitted to the hospital and informs the nurse that it is the month of Ramadan. Which action by the nurse is most appropriate in caring for this patient? a. Provide a vegetarian diet for the patient on Friday throughout her hospitalization. b. Ask the dietitian to visit the patient to ensure that fruit and cheese are not combined. c. Check on the potential effect fasting until sundown will have on the patient’s condition. d. Document that milk and milk products cannot be prepared with meat or meat products. 10. A 15-year-old female gymnast is hospitalized with the diagnosis of bulimia nervosa. Which data would the nurse anticipate finding in the patient’s admission history and physical assessment? a. Excessive intake of food, self-induced vomiting, and use of laxatives b. Refusal to eat, body image disturbance, constipation, and amenorrhea c. Excessive exercise, refusal to eat, poor muscle tone, and social isolation d. Hair loss, BMI of 27, occasional use of diuretics, calorie intake 2200/day 11. A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider 12. The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema?

Review Questions a. b. c. d.

The proper way to position the patient Signs and symptoms of intolerance to the procedure Vital signs before the procedure Any past medical or surgical history related to the anus or rectum

13. To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake 14. While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, and the stoma is in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy 15. The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal 16. The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient’s meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing 17. A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Altered Skin Integrity b. Risk for Imbalanced Fluid Volume c. Acute Pain d. Self-Care Deficit: Toileting 18. A patient is scheduled for a colonoscopy. After pre-procedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. “I can have coffee the morning of the procedure.” b. “I should drink a red, sports drink the day before to stay hydrated.”

Review Questions c. “I should drink clear liquids for 2 days before the procedure.” d. “I will be able to drive home immediately after the procedure.” 19. Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise 20. When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to left side-lying (Sims) position. b. Perform hand hygiene and apply sterile gloves. c. Add room-temperature solution to enema bag. d. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. e. Raise container release clamps and allow solution to flow to fill tubing. f. Hang solution 45 to 60 cm (18 to 21 inches) above anus and instill rapidly. g. Clamp tubing after solution is instilled.

21. While a nurse is administering a cleansing enema, the patient reports abdominal cramping. What nursing intervention is appropriate at this time? Lower enema

22. A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube 3-4 inches/ 7.5-10 cm 23. A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which position is appropriate for this patient? Dorsal Recumbent 24.A nurse is preparing to administer an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for as 30 min

25.A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? Left Lateral Sims 26. A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. What is an appropriate step in the procedure? Warm the solution before installation...