Chapter 51 continued Flashcards
(113 cards)
1
Q
For a school aged child how many inches do you insert an enema toward the umbilicus?
A
3 - 4 inches
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
3
Q
Amount of enema given to a school child?
A
300 - 500mL
4
Q
Amount of enema given to a toddler?
A
250 - 350mL
5
Q
Amount of enema given to an infant?
A
50 - 150mL
6
Q
Proper positioning prevents _ of the colon?
A
Injury and over inflation
7
Q
Excess heat can cause the solution to?
A
Deteriorate or damage intestinal mucosa
8
Q
You should ask the client to lie in what position for the cleansing enema?
A
Left side/ in sim’s position
9
Q
A cold solution can cause?
A
Intestinal cramping and possible shock
10
Q
Store enemas solutions at what temperature?
A
Room temperature
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
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
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
14
Q
Drug to be administered rectally to cause immediate absorption?
A
Medicated Enema
15
Q
Small amount of oil is given in very small amounts must be retained to be effective?
A
Oil Retention Enema
16
Q
Small amount of olive or cotton seed oil given to protect or soothe mucous membrane?
A
Emollient Enema
17
Q
This drug helps destroy intestinal parasites?
A
Anthelmintic Enema
18
Q
Given to stimulate peristalsis so that flatus (gas) is expelled?
A
Carminative Enema
19
Q
Effective evacuation usually results in?
A
10 min
20
Q
Hypertonic solution it pulls water from the colon tissue into the colon by _ ?
A
Osmosis
21
Q
When giving a tap water enema be aware that tap water is _ and may cause _?
A
- Hypotonic
- Circulatory overload
22
Q
Solutions most commonly used for the cleansing enema?
A
Tap water or normal saline
23
Q
A change in color suggests a change in _ or _?
A
- GI functioning
- Stool contents
24
Q
Indicating hemorrhage high in the GI tract or swallowed blood from a mouth, nose, or throat injury or disorder?
A
Melena
25
Dark, black, or tarry stools usually indicate the presence of partially _ in the colon?
Digested blood
26
Bright red blood in or streaked on the outside of the stool indicates _ or _ often from _?
1. Rectal bleeding
2. Anal bleeding
3. Hemorrhoids
27
_ or _ stools indicate the abnormal presence of microorganisms, suggesting infection?
Yellow or Greenish
28
_ 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?
Constipation
29
This enema has a specially formulated solution that helps produce or empties the rectum and lower colon?
Cleansing
30
Constipation also results if the person has not taken enough fluids or has not had sufficient exercise to stimulate _?
Peristalsis
31
This may occur if a person routinely ignores the impulse to empty the rectum?
Chronic constipation
32
Due to the presence of bile normally feces are _ in color?
Yellowish brown
33
The small volume fleet is usually ordered for the client and family to administer. What is the order given called?
Enemas until clear
No more than 500mL
At a time
34
Inspection of the rectum or lower colon by surgical means?
Proctoscopy
Or colonoscopy
35
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 _?
1. Contraindicated
2. Strain
3. Forceful evacuation
36
Large volume enemas contain how much solution?
1,500mL
37
Small- volume (fleet) contain how much hypertonic solution?
120-180 mL
38
Two basic systems are used for most enema administration?
1. Fleet ( small volume)
2. Large volume
39
An enema is often given for these two procedures?
1. Colonoscopy
2. Bowel surgery
40
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?
Enema
41
Suppositories can be administered _,_, or into the _?
1. Rectally
2. Vaginally
3. Urethra
42
A bullet shaped soft wax like mass inserted into the body’s opening for medication purposes by lubricating the area before administering?
Suppository
43
Residual over 150 mL may require?
1. Catherization
2. Other interventions
44
Residual over 50 mL in a young person and more than 50mL- 100mL in an older person is considered?
Significant
45
A residual urine is less than _ is considered adequate bladder emptying?
50mL
46
Volume of urine in the bladder after the client voids can be measured by noninvasive ultrasound (Doppler) bladder scanner?
Residual urine
47
Side effects may cause extreme dry mouth and constipation the Botox procedure may cause _?
Urinary retention
48
A newer procedure involves the injection of _ into bladder wall for bladder retraining?
Botox
49
Recommend to increase sphincter tone?
Kegel exercises
50
If after 1 year this conservative made of treatment is not effective corrective surgery may be available?
Bladder retraining
51
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
B. Toileting
52
It is important to communicate clearly so proper diagnosis and treatment can’t take place. True or false
False
53
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
True
54
Hyperactive bowel sounds indicate?
Diarrhea
Or
Early bowel obstruction
55
Bowel sounds are described as?
Audible, hypo/hyperactive
Inaudible
56
The normal range of peristalsis sounds per minute?
4 - 32
57
Peristalsis sounds usually occur about every _ seconds?
5 - 20
58
Peristalsis makes what sounds that vary in intensity, frequency, and pitch?
Bubbling
Gurgling
Or clicking sounds
59
Why should the nurse always follow the same pattern when auscultating the bowels?
Following a specific pattern promotes efficiency and helps to remember to listen to each area. This improves chances of hearing all bowel sounds
60
Why does the nurse need to warm the diaphragm of the stethoscope before auscultating the bowels?
The shock of a cold stethoscope can temporarily halt bowel sounds.
61
The client may have flatus, fecal impaction, or an intestinal obstruction if the abdomen feels _, _, or _?
1. Hard
2. Swollen
3. Tender
62
Sounds that indicate that the bowel is not functioning properly?
Diminished or absent
63
Simethicone is used to treat what condition?
Flatulence
64
Certain foods that cause excess gas to form and cause discomfort?
Broccoli, beans, cauliflower, and spicy foods
65
Most flatus is reabsorbed through the _ of the intestinal wall?
Vasculature
66
Expelling excess gas from the intestines is called?
Flatulence
67
Each person’s bowel patterns of elimination are unique to them.
True or false
True
68
The fecal mass causes pressure against _ which signals to the person they must defecate?
The bowel walls
69
What digital technique does the nurse use on the client during fecal disimpaction?
Two digits (fingers) in scissor motions to cut up small portions in the anus.
70
After manual disimpaction the client may have several bouts of _ before reestablishing a normal bowel elimination pattern?
Explosive diarrhea
71
Symptoms of fecal impaction include _, _, and a feeling of _?
1. Severe abdominal discomfort
2. Hard abdomen
3. Pressure
72
Bladder incontinence is more difficult to control than bowel incontinence.
True or false
True
73
This may occur in people of age and clients who have given birth as a result of child birth trauma?
Urinary Incontinence
74
Check the catheter and the circulation in the penis at least every _ ?
4 hours
75
Noninvasive approach to managing urinary incontinence?
External catheter
Or
Condom catheter
76
The client needs instructions on caring for the drainage system to prevent complications before discharge what might the nurse do?
1. Ask client to do a return demonstration after your demonstration
2. Offer gloves
77
The bag should be below the level of the bladder. If tubing kinks or hangs down or bag is to high what may happen?
Drainage will be slowed and infection can occur due to urine back flow
78
Ensure that the tubing falls straight down from the bed to the drainage bag. This is called?
Gravity or straight drainage
79
The weight of the clients leg might slow or stop drainage if the tubing is not positioned where?
Over the clients leg
80
An antimicrobial ointment may be applied to the meatal area after cleansing per agency protocol. What is the nursing rationale for this?
This can help prevent infections
81
Cleanse the urethral meatus and the first _ inches of exposed catheter twice daily with mild soap and water as ordered?
3 - 4 inches
82
Properly securing the catheter prevents _ and _ to the urethral meatus and prevents the catheter from being pulled out?
1. Pressure
2. Irritation trauma
83
By using the specimen port with a syringe to aspirate the contents we are obtaining a _ from the catheter?
Sterile urine specimen
84
Should you irrigate catheters without an order from the physician?
True or false
False
85
Have been a major cause of hospital _ acquired infections?
Indwelling catheters
86
Inserted via small incision ( stab wound) through lower abdominal wall above the symphysis pubis into the urinary bladder?
Suprapubic catheter
87
What catheter is balloned to inflation and plugged that has 2 lumens tube like?
Foley catheter
88
Catheter that is anchored in the bladder and drains continuously?
Retention catheter
(Indwelling catheter)
89
What catheter is removed and discarded after urine is drained?
Straight catheter
90
It is approximately 24 inches long is inserted into the bladder through the urethra using sterile technique?
Urinary catheter
91
Rinse bedpans and urinals with cool to tempid water because Hot water will cause the proteins in wastes to?
Coagulate
92
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?
Urge to void
93
Why should the nurse make sure the name of the client is on the bedpan and put in a private cabinet?
Each client has a separate bedpan to avoid cross- contamination
94
This helps prevent the spread of infection pertains to the use of bedpans and urinals?
They are disposable and should be discarded when the client no longer needs them.
95
What is the weight limit for wall mounted toilets?
400lbs
96
The expulsion of loose watery unformed stools frequently also known as explosive?
Diarrhea
97
Morphine, narcotics, drugs to lower bladder motility or after surgery of immobility, anesthesia, surgical trauma, and drying agents, atropine may cause?
Constipation
98
Continuing diarrhea suggests _, _, _, or a _?
1. Chronic colon irritation
2. Intestinal infection
3. Food poisoning
4. Parasitic infection
99
Diarrhea can also be a sign of _?
Fecal Impaction
100
Stool’s have the same shape as the bowels interior which is _, _, or _?
1. Round
2. Oval
3. Cylindrical
101
Long, thin, pencil like stools suggest a narrowing of the rectum or anal opening which could be caused by a _ or _?
1. Mass
2. Tumor
102
Stool that assumes the same irregular shape suggest a _ in the rectum or anus?
Abnormal growth
103
The gaseous discharge that occurs with or without a bowel movement can have a very strong odor?
Flatus
104
Floating stools are less dense and suggest what in the stool?
Undigested fats
105
Is the term used to identify stools with a high fat content?
Steatorrhea
106
If a stool _ may be an indication of gallbladder disease or cystic fibrosis?
Floats
107
The presence of _ or _ in stool might be signs of inflammation or infection in the GI system?
1. Pus
2. Mucus
108
Food products or medication tablets that goes Undigested may be due to?
GI malfunction
109
Hard and dry or putty like stool that after laxatives and enemas a client still cannot defecate is called?
Fecal Impaction
110
Result of chronic bowel problems?
Immobility, paralysis, or dehydration
111
A client has been diagnosed with fecal impaction following a
x-ray procedure after receiving an barium enema what has caused
this Impaction?
Retained barium
112
A client is being treated for _ to receive charcoal to later have black stools during defecation?
Poisoning
113
Normal stools are _ and _?
Soft and formed
