NUR 167 CHP 26,30 Study Guide with
Questions and Correct Answers
The nurse is caring for a client admitted through the emergency department (ED)
following an accident. The clients injuries include an i open fracture of the leg and
multiple bruises. Which terminology will the nurse use to document the clients wounds?
Close the leg injury with multiple cuts
Massive bruising with broken bones
Compound leg fracture with multiple contusions
Puncture leg wound with surface skin scrapes ✅ANS-Compond leg fracture with
multiple contusions
This is correct . An open fracture is correctly reffered to as a compund fracture .
Contusions is the terminology use for brussing, this entry is an ecample of using correct
meidcal tereminiolgy
The nurse is providing care for a client after surgery for repair for a penetrating wound
to the abdomen. Which characteristic of the wound will make the nurse MOST vigilant
for signs of infection?
The object that entered the clients abdomen remained embedded until surgery
The object was removed by the first responders and the wound flushes for foreign
bodies
The object inflicted no injury on the clients internal organs or boney structures
The object was smooth nonporous mental, and a diameter less than one ince ✅ANS-
The object that entered the clients abdomen remained embedded until surgery
This is correct. The verity definition of a penetrating wound is that the object remains
embedded in the tissue. The degree of damage depend son the characteristics of the
penetrating object and any injury to internal structures. Because the object is left in
place until surgery there is more time for pathogens to migrate into surrounding tissues.
This scenario will make the nurse most vigilant for signs of infection.
The nurse is caring for a client with diabetes mellitus who has a non-healing wound on
the bottom of the foot. Which assessment finding causes the nurse to conclude that the
wound is likely infected with Clostridia?
A crackling sensation under the skin can be felt when palpating around the wound
The area surrounding the wound is dark red, swollen, and draining yellow exudate
The infected area around the wound appears to be expanding to surrounding tissue
,The wound drainage has a strong smell of rotten grapes and appears green in color.
✅ANS-A crackling sensation under the skin can be felt when palpating around the
wound
Wounds infected with Clostridia develop a condition called gas gangrene, which causes
a crackling that can be felt when the area around the wound is palpated. Gangrene is n
anaerobic infection and most often occurs in the areas of poor circulation such as the
lower extremities of a client with diabetes mellitus
The nurse is preparing to irrigate a clients wound with a syringe and sterile saltine.
Which action by the nurse demonstrates correct procedure?
The irrigation of th) ✅The solution flow is directed from the least contaminated to the
most contaminated area.
This is correct. The purpose of irrigating is to cleanse the wound of debris; therefore, the
irrigation solution should be directed from the least to the most contaminated areas.
Commonly, the flow of the solution is from the superior to inferior areas, which uses
gravity to help remove the debris
How do you administer medications for constipations ? ✅Medications for constipation
may work by directly stimulating peristalsis, softening the stool, or adding bulk to the
stool, Stool softeners and those that add bulk are safer than the laxatives that stimulate
peristalsis.
How do you administer medications for enemas ? ✅the instillation of a solution into the
colon via the rectum, to relieve the problem,
what is the temperature for enemas? ✅between 105°F and 110°F to avoid burning the
intestinal mucosa
How do you check water temperature for enemas and do you check it? ✅Use a bath
thermometer to check water temperature, if one is not available, pour a small amount of
the solution on the inner side of your bare wrist. It should feel warm but never hot.
Water that is too cold will cause abdominal cramping and may restrict the patient's
ability to retain the water.
How should you position your patient for a enema? ✅position the patient in the left
Sims' or left lateral side-lying position allows gravity to help pull the solution into the
intestine.
What are the contraindications to enema? ✅• Rectal surgery
• Severe bleeding hemorrhoids
• Ulcerative colitis or Crohn's disease
• Rectal fissure
,• Rectal cancer
• Excessive bleeding potential due to disease or medication
• Certain heart conditions, such as myocardial infarction or unstable angina
What are the complications of enema? ✅vagal response and perforation of the
intestinal wall, which can result in hemorrhage and infection.
What is vagal response ? ✅Any time you insert an enema tube into a patient's rectum,
there is the possibility of stimulating the vagus nerve, which innervates not only the GI
tract, but also the heart and bronchioles
TRUE OR FALSE
When the vagus nerve is stimulated, it can drop the heart rate as low as 30 to 40 beats
per minute (bpm) and cause constriction of the bronchioles of the lungs. As you know, a
heart rate of 30 or 40 bpm is insufficient to support adequate blood pressure and
circulation for longer than a few minutes, making it important to know the signs and
symptoms to watch for ✅True
When should you stop performing giving a enema? ✅Stop the enema
Remove the tube from the rectum
Place the patient in the supine position
Assess pulse rate, skin color, and whether or not the patient is diaphoretic
Call for immediate assistance, but do not leave the patient
If the pulse rate is below 60 bpm, place the patient in the shock position, with the head
lower than the feet
Assess blood pressure as soon as a cuff is available
Supply oxygen if needed
How should you perforate the colon? ✅Always be gentle when inserting an enema
tube; never force it or insert it farther than 4 to 6 inches. You should direct the tip of the
tubing toward the umbilicus to follow the natural direction of the sigmoid colon. If you
are not careful, it is possible to perforate, or go through, the intestinal wall. This can
result in introduction of bacteria into the sterile peritoneal cavity, bleeding, and even
hemorrhage. Again, never force the enema tubing if you meet resistance.
What are the symptoms of vagus nerve stimulation? ✅Chest pain
Chest heaviness or pressure
Shortness of breath or inability to breathe
Dizziness
Feeling like he or she is going to faint
Nausea
What are the signs of vagus nerve stimulation? ✅Pallor
Clammy skin
Pulse rate under 60 bpm
, True or False
A patient have to exhibit all of the signs and symptoms for you to stop administering the
enema or removing the impaction ✅True
How might fecal impaction occur? ✅may occur in the rectum, the sigmoid flexure, or
any part of the large colon. It is more common in elders, patients on bedrest, and
severely dehydrated patients, Any cause of constipation may lead also to impaction.
One common cause, especially in elderly patients, is the abuse of laxatives.
True of False
If an impaction is not relieved, obstruction or perforation of the bowel wall can occur.
✅True
how a patient with an impaction can exhibit signs of diarrhea? ✅liquid stool from higher
in the rectum or colon may seep around the solid impaction. When this happens, the
patient may think he or she has diarrhea or may notice smears of liquid stool in the
underwear or incontinence brie
What are the nursing interventions for fecal impaction? ✅it usually requires digital
removal before administering a cleansing enema. This involves insertion of the gloved
index finger into the anus to manually break the fecal mass into small pieces and
remove them from the rectum. This procedure may be embarrassing as well as painful
for the patient. To make the procedure less uncomfortable, it is helpful to instill an oil
retention enema about 1 hour prior to digital removal. Some patients may even require
mild pain medication to better tolerate the procedure.
What are things you must consider before actually removing the impaction? ✅First,
review the facility's policy and procedures to determine which personnel are permitted to
perform the procedure and whether or not a health-care provider's order is required,
Next, review the patient's medical record for all of the patient's diagnoses. The same
conditions that may contraindicate an enema may also contraindicate digital removal of
impaction by the nurse. Once you have determined it is safe, you may proceed,
Remember to monitor for signs of vagal nerve stimulation, just as you do with enema
administration.
True or False
May you delegate fecal impactation to a CNA or UAP? False Most hospitals do not
allow delegation of this procedure to a CNA or UAP. ✅True
Can you delegate administration of an enema to a UAP or a CNA? ✅Because you are
held responsible for safe and competent administration of the enema, it is very
important that you verify that the UAP or CNA has received specific training and is
competent in performance of the skill, documented in writing for your best protection,
assess the patient's condition and determine whether it is safe to have the UAP or CNA
