Description
Taylors Clinical Nursing Skills A Nursing Process 3rd Edition Lynn Test Bank
| ISBN-13: 978-0781793841
ISBN-10: 078179384X |
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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: | |
| A) | Duodenum | |
| B) | Jejunum | |
| C) | Ileum | |
| D) | Cecum | |
| 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? | |
| A) | Palpation | |
| B) | Percussion | |
| C) | Auscultation | |
| D) | Inspection | |
| 4. | Which of the following enema solutions lubricates the stool and intestinal mucosa without distending the intestine? | |
| A) | Water | |
| B) | Soap | |
| C) | Normal saline | |
| D) | Oil | |
| 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 | |
| B) | Abdominal tenderness | |
| C) | Areas of distention | |
| D) | Muscular resistance | |
| 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. | |
| A) | Hyperphosphatemia | |
| B) | Bleeding | |
| C) | Abscesses | |
| D) | Infection | |
| E) | Anal fissures | |
| F) | Hypervolemia | |
| 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 | |
| B) | Carminative enema | |
| C) | Anthelmintic enema | |
| D) | Nutritive 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 by 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? | |
| A) | Every shift | |
| 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 by 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? | |
| A) | Sigmoid colostomy | |
| B) | Ileostomy | |
| C) | Transverse colostomy | |
| D) | Ascending colostomy | |
| 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 | |
| C) | Every shift | |
| 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. | |
Answer Key
| 1. | B |
| 2. | D |
| 3. | A |
| 4. | D |
| 5. | A |
| 6. | B |
| 7. | A |
| 8. | B, D |
| 9. | B |
| 10. | C |
| 11. | C |
| 12. | D |
| 13. | A |
| 14. | C |
| 15. | D |
| 16. | C |
| 17. | D |
| 18. | A |
| 19. | B |
| 20. | A |
