Module 17: Bowel Elimination/Ostomy, Module 18 - Lesson 3 & 4,
Bowel Elimination / Ostomy Care, Urinary Catheterization, Module 17:
Lesson 6 Post-Test, NU 311 EXAM 4 Urinary Cath, Evolve - Urination,
Module 16 Urinary, N220: Oxygenation video quizzes...
From the following, choose the correct equipment to bring to the bedside to
administer the commercially prepared Fleet enema. (Select all that apply.)
Correct Answer(s): A, B, C, G, I, J
The supplies needed to administer a commercially prepared Fleet enema include the
commercially prepared enema product; clean disposable gloves; a waterproof bed pad;
water-soluble lubricant; a bedside commode; and toilet paper and/or a basin with warm
water, washcloth, and towel.
Which of the following would be inappropriate to delegate to NAP?
B) Pouching a newly established ostomy
Feedback: CORRECT
The skill of pouching an ostomy, especially a newly established ostomy, may not be
delegated. Pouching of an established ostomy may be delegated. The skill of
administering an enema may be delegated. NAP should be directed to monitor and
record the volume of ostomy output.
The nurse listens for bowel sounds prior to 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."
Feedback: CORRECT
Assessment of a patient before giving the enema should include determining the
presence of bowel sounds. Bowel sounds indicate peristalsis and can establish a
baseline for determining effectiveness.
Which of the following patients would it be considered acceptable to administer
an enema and the nurse would not need to question the order?
B) A patient who is going to have surgery
Feedback: CORRECT
An enema is often administered prior to surgery to evacuate the bowel. Conditions
which contraindicate use of enemas include the presence of increased intracranial
pressure, glaucoma, inflammatory bowel disease, or recent rectal or prostate surgery.
Which of the following would be considered a normal finding after the
administration and evacuation of an enema?
D) Abdominal distention is absent.
Feedback: CORRECT
An expected finding is that abdominal distention should be significantly diminished or
absent. Only a brief, small amount of hemorrhoidal bleeding is considered acceptable.
High-pitched and hyperactive bowel sounds occur with small intestine obstruction
and/or inflammatory disorders. Normal bowel sounds should be heard. If the patient
complains of a firm and painful abdomen, check vital signs. The patient may have
experienced a perforation of the bowel.
,The patient is complaining of cramping during instillation of the enema solution.
What is the most appropriate action by the nurse?
D) Lower the height of the enema container.
Feedback: CORRECT
The nurse should slow the rate of infusion by lowering the enema container. Having the
patient take slow breaths through the mouth may help them to relax.
Which of the following is considered a sterile procedure, and therefore requires
sterile gloves?
D) None of the above
Feedback: CORRECT
Pouching an ostomy and enema preparation/administration do not require sterile
technique as the bowel normally contains bacteria. Clean disposable gloves are
sufficient.
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.
Feedback: CORRECT
Taking a passive role in the care of the ostomy may indicate the patient is having
difficulty with the change in self-image. You can play an important role in helping the
patient with acceptance of the change in self-image. You must be cognizant of the
patient's readiness to learn. If the patient is apprehensive about touching or looking at
the stoma, have the patient hold a gauze pad over the stoma and clean around the
stoma.
How often should an ostomy pouch be changed?
A) 3 to 7 days
Feedback: CORRECT
Intact skin barriers without evidence of leakage can remain in place for 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?
D) "The stoma typically increases in size with the passage of time."
Feedback: CORRECT
The stoma will shrink and reach usual stoma size in 6 to 8 weeks. The nurse should
measure the stoma each time to ensure the correct size of appliance is used. (NOTE:
The module DOES NOT teach this. You can verify this at other sites like ostomy.org)
The NAP tells the nurse she doesn't 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."
Feedback: CORRECT
The best prevention for health care workers from acquiring infectious illness is good
hand hygiene. Clostridium difficile (C. difficile) infection may be acquired in one of two
ways, by factors that cause an overgrowth of C. difficile and by contact with the C.
difficile organism. H. pylori is the organism responsible for duodenal ulcers. The nurse
,should instruct the NAP on personal protection as it is not always known or possible to
avoid patients with an infectious illness.
The nurse instructs the patient that his physician has ordered for him to receive
an enema. The patient states, "An enema! I'm not constipated." What are other
possible reasons for the order? (Select all that apply.)
Correct Answer(s): A, B, C, D
An enema is a procedure that involves the instillation of a specific solution into the
rectum and the sigmoid colon in an effort to treat constipation or to prepare the patient
for a diagnostic procedure or abdominal surgery. Enemas are also a vehicle for
medications that exert a local effect on rectal mucosa. Other indications include
removing impacted feces, and beginning a program of bowel training.
Match the type of colostomy construction to the correct description:
1. Double barrel = Bowel is surgically severed and the two ends are brought out onto
the abdomen
2. Loop = Two openings through one stoma; the proximal end drains stool and the distal
portion drains mucus
3. End = One stoma formed from the proximal end of the bowel with the distal portion of
the GI tract either removed or sewn closed
4. Ileoanal pouch anastomosis - Colon is removed; pouch is created from end of the
small intestine and is attached to anus.
5. Ileostomy - Placed in the transverse or ascending colon.
A patient has a loop colostomy. The patient complains that the distal stoma looks
like it is secreting mucus. What is your best response?
"The distal stoma of a loop colostomy is the functional end that excretes urine
and requires more frequent changing of the pouch."
"Let me take a look at your pouch of the distal stoma; perhaps it is leaking."
"The distal stoma may secrete mucus and that would be normal."
"The proximal stoma secretes mucus but otherwise is considered nonfunctional.
The output from the distal stoma is called effluent."
"The distal stoma may secrete mucus and that would be normal."
The distal stoma is the nonfunctional end. It may secrete mucus. The proximal stoma of
the loop colostomy is the functional end that excretes effluent. A loop colostomy is a
bowel diversion and is without connection to the urinary system.
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?
"It will be a change for you, but a normal lifestyle is still possible. What concerns
you the most?"
"Don't worry, many patients have had this same surgery and learn to manage
very well."
"You sound like you are in disbelief. Why do you feel this way?"
"How has your husband reacted to the news?"
"It will be a change for you, but a normal lifestyle is still possible. What concerns you the
most?"
, An important aspect of patient teaching by you, the nurse, is to help the ostomy patient
develop acceptance of a change in body image and realization that a normal lifestyle is
still possible. Asking "why" can make the patient feel defensive. Telling the patient not to
worry fails to acknowledge their feelings and is nontherapeutic. Although determining
whether the patient has a support system is important, asking about how the family
feels ignores the patient's feelings.
A patient is scheduled to have an ileostomy. The patient asks, "Will I always have
to wear a pouch?" The nurse's best response is:
"An ileostomy generally results in formed stool, so you may not have to wear a
pouch at all times."
"Unless an internal pouch is surgically created, the effluent of an ileostomy is
very liquid and must be pouched at all times."
"It really depends on your diet. Some patients are able to regulate their ileostomy
by performing daily irrigations, usually in the morning after breakfast."
"An ileostomy can be regulated by inserting a catheter and emptying it as
needed, so a pouch is unnecessary."
"Unless an internal pouch is created. An ileostomy bypasses the entire large intestine,
so stools are liquid and frequently contain digestive enzymes and so must be pouched
at all times."
With an ileostomy the fecal effluent leaves the body before it enters the colon, creating
frequent, liquid stools. An ileostomy drains fecal effluent that is watery to thick and
contains some digestive enzymes. A colostomy of the sigmoid colon generally results in
formed stool.
The nurse is pouching an enterostomy. Assuming all other steps are performed
correctly, which of the following steps is incorrect?
The nurse applies the pouch over the stoma pressing firmly around stoma and
outside edges, and has the patient hold hand over pouch to apply heat to secure
seal.
The nurse cleans the peristomal skin vigorously with warm tap water, selects a
pouch, removes the backing and cuts the opening on the pouch to one-quarter
inch larger than the stoma.
The nurse removes drape from patient, removes gloves, and performs hand
hygiene. The nurse documents the procedure.
The nurse observes the skin barrier for leakage and length of time in place.
The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch,
removes the backing and cuts the opening on the pouch to one-quarter inch larger than
the stoma.
T
o correctly perform the procedure, the nurse performs hand hygiene, auscultates for
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