Taylors Clinical Nursing Skills A Nursing Process 3rd Edition Lynn Test Bank
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Below you will find some free nursing test bank questions from this test bank:
|1.||A physician orders a large volume cleansing enema for a patient postabdominal surgery. What is one of the usual outcomes of this procedure?|
|A)||It stimulates peristalsis and provides a passageway for gas to escape.|
|B)||It removes hardened fecal impactions from the rectum.|
|C)||It provides an outlet for diarrhea to be funneled into a collection unit.|
|D)||It softens and facilitates the removal of intestinal polyps.|
|2.||A student nurse studying human anatomy knows that the following is a structure of the large intestine:|
|3.||A nurse is performing an abdominal assessment of a patient before administering a large-volume cleansing enema. Which of the following assessment techniques would be performed last?|
|4.||Which of the following enema solutions lubricates the stool and intestinal mucosa without distending the intestine?|
|5.||A physician orders an enema to effect rapid colonic emptying in a patient who is experiencing severe abdominal cramping due to constipation. What type of solution would be best suited to this patient’s needs?|
|A)||Large-volume cleansing enema with hypotonic solution|
|B)||Small-volume cleansing enema with hypotonic solution|
|C)||Small-volume cleansing enema with isotonic solution|
|D)||Large-volume cleansing enema with oil|
|6.||For which one of the following patients would a hypertonic solution enema be contraindicated?|
|A)||A patient who is constipated|
|B)||A patient with renal impairment|
|C)||A patient who has diarrhea|
|D)||A patient who has cancer|
|7.||A nurse assesses the abdomen of a patient before and after administering a small-volume cleansing enema. What condition would be an expected finding?|
|A)||Increased bowel sounds|
|C)||Areas of distention|
|8.||A nurse checks the laboratory report for a patient who has an order for a small-volume cleansing enema. The nurse finds that the patient has a WBC of 19,050 and notifies the primary care provider. For what conditions would this patient be at risk? Select all that apply.|
|9.||A nurse is giving an enema to a patient who doubles over in pain with severe cramping. What intervention would be appropriate in this situation?|
|A)||Remove the tubing and discontinue the procedure.|
|B)||Lower the solution container and check the temperature and flow rate.|
|C)||Place the patient on a bedpan in the supine position while receiving the enema.|
|D)||Reposition the rectal tube and check for any fecal content.|
|10.||A physician orders a retention enema for a patient to destroy intestinal parasites. Which of the following enemas would be indicated for this patient?|
|A)||Oil retention enema|
|11.||A nurse follows a physician’s order to administer an oil retention enema to a constipated adult patient. Which of the following is a recommended guideline for this procedure?|
|A)||Put on sterile gloves to perform the procedure.|
|B)||Slowly and gently insert rectal tube 4 to 6 inches.|
|C)||Direct the rectal tube at an angle pointing toward the umbilicus.|
|D)||Instruct the patient to retain the enema solution for at least 45 minutes.|
|12.||A nurse attempts to administer a nutritive retention enema to a patient who is dehydrated and finds that the patient cannot retain the enema for the prescribed amount of time. Which of the following would be a recommended intervention for this patient?|
|A)||Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the physician.|
|B)||Place the patient in a sitting position on the toilet and lower the enema solution.|
|C)||Stop the enema and reposition the rectal tube or remove it to check for any fecal contents.|
|D)||Place the patient on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.|
|13.||For which of the following patients would digital removal of stool be contraindicated?|
|A)||A patient recovering from prostate surgery|
|B)||A diabetic patient with renal complications|
|C)||An elderly patient who is incontinent of stool|
|D)||A patient with a UTI|
|14.||A nurse is ordered to perform digital removal of stool on a patient with stool impaction. Which of the following is an appropriate step in this procedure?|
|A)||Position the patient in supine position as dictated patient comfort and condition.|
|B)||Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus.|
|C)||Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.|
|D)||Instruct the patient not to bear down while extracting feces to prevent vagal response.|
|15.||How often should a fecal incontinence pouch be removed to check for signs of skin breakdown?|
|B)||Every 24 hours|
|C)||Every 36 hours|
|D)||Every 72 hours|
|16.||A nurse is teaching a patient how to change his ostomy appliance. Which of the following is an accurate step that should be incorporated into the teaching plan?|
|A)||Gently remove the pouch faceplate from the skin pulling the appliance from the skin.|
|B)||If the appliance is reusable, set it aside to wash it in alcohol and allow it to air dry.|
|C)||Use toilet tissue to remove any excess stool from the stoma.|
|D)||Apply skin protectant to a 6-inch radius around the stoma, and allow it to dry completely for 30 minutes.|
|17.||A nurse assessing a patient with an ostomy appliance documents the condition “prolapse” in the patient chart and notifies the physician. Which of the following statements describes this condition?|
|A)||The peristomal skin is excoriated or irritated because the appliance is cut too large.|
|B)||The system has leaks or poor adhesion leading to noticeable odor.|
|C)||The bag continues to come loose and become inverted.|
|D)||The stoma is protruding into the bag and may become twisted.|
|18.||What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?|
|19.||A nurse is caring for a patient with an NG tube to monitor for GI bleeding. How often should the nurse irrigate the tube?|
|A)||Every 2 to 4 hours|
|B)||Every 4 to 6 hours|
|D)||Every 24 hours|
|20.||A nurse is following a physician’s order to irrigate the NG tube of a patient. Which of the following is a recommended guideline in this procedure?|
|A)||Assist patient to 30- to 45-degree position, unless this is contraindicated.|
|B)||Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe.|
|C)||If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent.|
|D)||If unable to irrigate the tube, reposition patient and attempt irrigation again; inject 20 to 30 mL of air and aspirate again.|