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Unit 9: Elimination and Dx Tests > Chapter 51 continued > Flashcards

Chapter 51 continued Flashcards

1
Q

For a school aged child how many inches do you insert an enema toward the umbilicus?

A

3 - 4 inches

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2
Q

The anus has inside and outside _ muscles that control the opening to the outside body. Must be inserted carefully past both of these?

A

Sphincters

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3
Q

Amount of enema given to a school child?

A

300 - 500mL

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4
Q

Amount of enema given to a toddler?

A

250 - 350mL

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5
Q

Amount of enema given to an infant?

A

50 - 150mL

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6
Q

Proper positioning prevents _ of the colon?

A

Injury and over inflation

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7
Q

Excess heat can cause the solution to?

A

Deteriorate or damage intestinal mucosa

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8
Q

You should ask the client to lie in what position for the cleansing enema?

A

Left side/ in sim’s position

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9
Q

A cold solution can cause?

A

Intestinal cramping and possible shock

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10
Q

Store enemas solutions at what temperature?

A

Room temperature

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11
Q

Measuring the clients abdominal girth before and after a procedure of an enema is good practice to determine?

A

If gas was expelled and distention is relieved

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12
Q

The Harris flush is to relieve intestinal gas and distention which causes pain. What is another name for this enema?

A

The Return Flow

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13
Q

Recommend times to hold the enemas of cleansing, retention, and medicated?

A

Cleansing- 5-10min
Retention- 25-30 min
Medicated- try not to expel

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14
Q

Drug to be administered rectally to cause immediate absorption?

A

Medicated Enema

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15
Q

Small amount of oil is given in very small amounts must be retained to be effective?

A

Oil Retention Enema

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16
Q

Small amount of olive or cotton seed oil given to protect or soothe mucous membrane?

A

Emollient Enema

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17
Q

This drug helps destroy intestinal parasites?

A

Anthelmintic Enema

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18
Q

Given to stimulate peristalsis so that flatus (gas) is expelled?

A

Carminative Enema

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19
Q

Effective evacuation usually results in?

A

10 min

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20
Q

Hypertonic solution it pulls water from the colon tissue into the colon by _ ?

A

Osmosis

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21
Q

When giving a tap water enema be aware that tap water is _ and may cause _?

A
  1. Hypotonic
  2. Circulatory overload
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22
Q

Solutions most commonly used for the cleansing enema?

A

Tap water or normal saline

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23
Q

A change in color suggests a change in _ or _?

A
  1. GI functioning
  2. Stool contents
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24
Q

Indicating hemorrhage high in the GI tract or swallowed blood from a mouth, nose, or throat injury or disorder?

A

Melena

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25
Q

Dark, black, or tarry stools usually indicate the presence of partially _ in the colon?

A

Digested blood

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26
Q

Bright red blood in or streaked on the outside of the stool indicates _ or _ often from _?

A
  1. Rectal bleeding
  2. Anal bleeding
  3. Hemorrhoids
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27
Q

_ or _ stools indicate the abnormal presence of microorganisms, suggesting infection?

A

Yellow or Greenish

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28
Q

_ is a result of hard, dry stools when the rectum has not been emptied as needed or excess liquid has been absorbed by the body?

A

Constipation

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29
Q

This enema has a specially formulated solution that helps produce or empties the rectum and lower colon?

A

Cleansing

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30
Q

Constipation also results if the person has not taken enough fluids or has not had sufficient exercise to stimulate _?

A

Peristalsis

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31
Q

This may occur if a person routinely ignores the impulse to empty the rectum?

A

Chronic constipation

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32
Q

Due to the presence of bile normally feces are _ in color?

A

Yellowish brown

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33
Q

The small volume fleet is usually ordered for the client and family to administer. What is the order given called?

A

Enemas until clear
No more than 500mL
At a time

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34
Q

Inspection of the rectum or lower colon by surgical means?

A

Proctoscopy
Or colonoscopy

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35
Q

Increased inter cranial pressure (ICP), recent brain surgery or brain tumor, rectal prolapse, uterine prolapse, unrepaired hernia, eye or ear surgery, recent rectal surgery, recent hemorrhage anywhere in body including nose bleed, uncontrolled high blood pressure, other instances determined by physician are conditions that are _ to the _ of the bowels being _?

A
  1. Contraindicated
  2. Strain
  3. Forceful evacuation
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36
Q

Large volume enemas contain how much solution?

A

1,500mL

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37
Q

Small- volume (fleet) contain how much hypertonic solution?

A

120-180 mL

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38
Q

Two basic systems are used for most enema administration?

A
  1. Fleet ( small volume)
  2. Large volume
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39
Q

An enema is often given for these two procedures?

A
  1. Colonoscopy
  2. Bowel surgery
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40
Q

A solution into the rectum and colon usually given to stimulate peristalsis causing elimination of stool or medication and therapeutic agents may be given this way?

A

Enema

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41
Q

Suppositories can be administered ,, or into the _?

A
  1. Rectally
  2. Vaginally
  3. Urethra
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42
Q

A bullet shaped soft wax like mass inserted into the body’s opening for medication purposes by lubricating the area before administering?

A

Suppository

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43
Q

Residual over 150 mL may require?

A
  1. Catherization
  2. Other interventions
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44
Q

Residual over 50 mL in a young person and more than 50mL- 100mL in an older person is considered?

A

Significant

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45
Q

A residual urine is less than _ is considered adequate bladder emptying?

A

50mL

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46
Q

Volume of urine in the bladder after the client voids can be measured by noninvasive ultrasound (Doppler) bladder scanner?

A

Residual urine

47
Q

Side effects may cause extreme dry mouth and constipation the Botox procedure may cause _?

A

Urinary retention

48
Q

A newer procedure involves the injection of _ into bladder wall for bladder retraining?

49
Q

Recommend to increase sphincter tone?

A

Kegel exercises

50
Q

If after 1 year this conservative made of treatment is not effective corrective surgery may be available?

A

Bladder retraining

51
Q

Various nursing interventions to assist the client with either bowel or bladder elimination may be called? Select all that apply?
A. Peeing B. Toileting
C. Defecation D. Dunny

A

B. Toileting

52
Q

It is important to communicate clearly so proper diagnosis and treatment can’t take place. True or false

53
Q

Hypoactive bowel sounds are absent and often occur after abdominal surgery, late bowel obstruction or paralytic ileus affected by spinal cord trauma. True or false

54
Q

Hyperactive bowel sounds indicate?

A

Diarrhea
Or
Early bowel obstruction

55
Q

Bowel sounds are described as?

A

Audible, hypo/hyperactive
Inaudible

56
Q

The normal range of peristalsis sounds per minute?

57
Q

Peristalsis sounds usually occur about every _ seconds?

58
Q

Peristalsis makes what sounds that vary in intensity, frequency, and pitch?

A

Bubbling
Gurgling
Or clicking sounds

59
Q

Why should the nurse always follow the same pattern when auscultating the bowels?

A

Following a specific pattern promotes efficiency and helps to remember to listen to each area. This improves chances of hearing all bowel sounds

60
Q

Why does the nurse need to warm the diaphragm of the stethoscope before auscultating the bowels?

A

The shock of a cold stethoscope can temporarily halt bowel sounds.

61
Q

The client may have flatus, fecal impaction, or an intestinal obstruction if the abdomen feels _, _, or _?

A
  1. Hard
  2. Swollen
  3. Tender
62
Q

Sounds that indicate that the bowel is not functioning properly?

A

Diminished or absent

63
Q

Simethicone is used to treat what condition?

A

Flatulence

64
Q

Certain foods that cause excess gas to form and cause discomfort?

A

Broccoli, beans, cauliflower, and spicy foods

65
Q

Most flatus is reabsorbed through the _ of the intestinal wall?

A

Vasculature

66
Q

Expelling excess gas from the intestines is called?

A

Flatulence

67
Q

Each person’s bowel patterns of elimination are unique to them.
True or false

68
Q

The fecal mass causes pressure against _ which signals to the person they must defecate?

A

The bowel walls

69
Q

What digital technique does the nurse use on the client during fecal disimpaction?

A

Two digits (fingers) in scissor motions to cut up small portions in the anus.

70
Q

After manual disimpaction the client may have several bouts of _ before reestablishing a normal bowel elimination pattern?

A

Explosive diarrhea

71
Q

Symptoms of fecal impaction include _, _, and a feeling of _?

A
  1. Severe abdominal discomfort
  2. Hard abdomen
  3. Pressure
72
Q

Bladder incontinence is more difficult to control than bowel incontinence.
True or false

73
Q

This may occur in people of age and clients who have given birth as a result of child birth trauma?

A

Urinary Incontinence

74
Q

Check the catheter and the circulation in the penis at least every _ ?

75
Q

Noninvasive approach to managing urinary incontinence?

A

External catheter
Or
Condom catheter

76
Q

The client needs instructions on caring for the drainage system to prevent complications before discharge what might the nurse do?

A
  1. Ask client to do a return demonstration after your demonstration
  2. Offer gloves
77
Q

The bag should be below the level of the bladder. If tubing kinks or hangs down or bag is to high what may happen?

A

Drainage will be slowed and infection can occur due to urine back flow

78
Q

Ensure that the tubing falls straight down from the bed to the drainage bag. This is called?

A

Gravity or straight drainage

79
Q

The weight of the clients leg might slow or stop drainage if the tubing is not positioned where?

A

Over the clients leg

80
Q

An antimicrobial ointment may be applied to the meatal area after cleansing per agency protocol. What is the nursing rationale for this?

A

This can help prevent infections

81
Q

Cleanse the urethral meatus and the first _ inches of exposed catheter twice daily with mild soap and water as ordered?

A

3 - 4 inches

82
Q

Properly securing the catheter prevents _ and _ to the urethral meatus and prevents the catheter from being pulled out?

A
  1. Pressure
  2. Irritation trauma
83
Q

By using the specimen port with a syringe to aspirate the contents we are obtaining a _ from the catheter?

A

Sterile urine specimen

84
Q

Should you irrigate catheters without an order from the physician?
True or false

85
Q

Have been a major cause of hospital _ acquired infections?

A

Indwelling catheters

86
Q

Inserted via small incision ( stab wound) through lower abdominal wall above the symphysis pubis into the urinary bladder?

A

Suprapubic catheter

87
Q

What catheter is balloned to inflation and plugged that has 2 lumens tube like?

A

Foley catheter

88
Q

Catheter that is anchored in the bladder and drains continuously?

A

Retention catheter
(Indwelling catheter)

89
Q

What catheter is removed and discarded after urine is drained?

A

Straight catheter

90
Q

It is approximately 24 inches long is inserted into the bladder through the urethra using sterile technique?

A

Urinary catheter

91
Q

Rinse bedpans and urinals with cool to tempid water because Hot water will cause the proteins in wastes to?

92
Q

For difficulty voiding include sound of running water, put clients hands in warm water, pouring water over the female genitalia, provide privacy, soothing music, or visualization of a gentle mountain stream, warm shower or bath and encourage to drink small amount of water. These stimulate what?

A

Urge to void

93
Q

Why should the nurse make sure the name of the client is on the bedpan and put in a private cabinet?

A

Each client has a separate bedpan to avoid cross- contamination

94
Q

This helps prevent the spread of infection pertains to the use of bedpans and urinals?

A

They are disposable and should be discarded when the client no longer needs them.

95
Q

What is the weight limit for wall mounted toilets?

96
Q

The expulsion of loose watery unformed stools frequently also known as explosive?

97
Q

Morphine, narcotics, drugs to lower bladder motility or after surgery of immobility, anesthesia, surgical trauma, and drying agents, atropine may cause?

A

Constipation

98
Q

Continuing diarrhea suggests _, _, _, or a _?

A
  1. Chronic colon irritation
  2. Intestinal infection
  3. Food poisoning
  4. Parasitic infection
99
Q

Diarrhea can also be a sign of _?

A

Fecal Impaction

100
Q

Stool’s have the same shape as the bowels interior which is _, _, or _?

A
  1. Round
  2. Oval
  3. Cylindrical
101
Q

Long, thin, pencil like stools suggest a narrowing of the rectum or anal opening which could be caused by a _ or _?

A
  1. Mass
  2. Tumor
102
Q

Stool that assumes the same irregular shape suggest a _ in the rectum or anus?

A

Abnormal growth

103
Q

The gaseous discharge that occurs with or without a bowel movement can have a very strong odor?

104
Q

Floating stools are less dense and suggest what in the stool?

A

Undigested fats

105
Q

Is the term used to identify stools with a high fat content?

A

Steatorrhea

106
Q

If a stool _ may be an indication of gallbladder disease or cystic fibrosis?

107
Q

The presence of _ or _ in stool might be signs of inflammation or infection in the GI system?

108
Q

Food products or medication tablets that goes Undigested may be due to?

A

GI malfunction

109
Q

Hard and dry or putty like stool that after laxatives and enemas a client still cannot defecate is called?

A

Fecal Impaction

110
Q

Result of chronic bowel problems?

A

Immobility, paralysis, or dehydration

111
Q

A client has been diagnosed with fecal impaction following a
x-ray procedure after receiving an barium enema what has caused
this Impaction?

A

Retained barium

112
Q

A client is being treated for _ to receive charcoal to later have black stools during defecation?

113
Q

Normal stools are _ and _?

A

Soft and formed

Unit 9: Elimination and Dx Tests (5 decks)

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