Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NSG 1101 > Unit 4: Elimination > Flashcards

Unit 4: Elimination Flashcards

1
Q

What is the usual amount of solution ordered for a large-volume cleansing enema?

A

~1,000 ml

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How high do you hold the solution container when delivering an enema?

A

12-18 inches above the anus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What position should the patient be placed in for an enema?

A

Left Lateral (Sims)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What should the nurse instruct the patient to do when inserting the enema tube?

A

Take a deep breath.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What steps should the nurse take if the patient experiences cramping during the administration of an enema?

A

Clamp the tubing, instruct the patient to take deep breaths, wait for cramping to subside, and resume the enema at a slower rate.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How do you adjust the rate of flow for an enema?

A

Adjust the height of the container.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How far is the enema tube inserted into the rectum for adults?

A

2-4 inches

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the signs of a fecal impaction?

A

Pain and Distention.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What type of bowel sounds would the nurse expect to hear above the area of a fecal impaction?

A

Hyperactive bowel sounds.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What type of bowel sounds would the nurse expect to hear below the site of a fecal impaction?

A

Hypoactive bowel sounds or no bowel sounds.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

The physician has ordered for examination of the rectal vault and digital evacuation of any impacted stool. Why can this task not be delegated?

A

Digitally disimpacting can cause vagal stimulation and may result in bradycardia. The nurse will need to monitor the patient for signs of bradycardia, such as diaphoresis and pallor.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

When performing an examination of the rectal vault, what should the nurse monitor the patient for?

A

Vagal Stimulation- Signs of bradycardia: Diaphoresis and pallor.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What type of catheter remains in place of extended periods of time?

A

Indwelling/Retention/Foley

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What type of catheter is placed for a short period of time, typically to obtain a specimen or drain the bladder?

A

Straight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What type of catheter is used to measure residual urine to assess urinary retention?

A

Straight catheter.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

When performing a straight catheterization how much urine can be drained from the bladder at one time?

A

1000 ml.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Urine left in the bladder after voiding is termed:

A

Residual Urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

A triple lumen catheter is used to:

A

Drain the bladder, and irrigate the bladder with fluid or medication.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

When is a triple lumen catheter generally used?

A

Following urologic or prostatic surgery.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What benefit do silver-impregnated/coated catheters provide?

A

Developed to delay the occurrence of bacteriuria and prevent urethral entry of microorganisms.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

A patient has significant urethral narrowing due to prostatic hyperplasia. What type of catheter would allow for best insertion through the urethra?

A

Catheter Coudé

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the two common drawbacks with external catheters? (Condom/Texas Catheter)

A

Dislodgment and Leakage.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

A patient who cannot void due to permanent narrowing of the urethra may be a candidate for what type of catheter?

A

Suprapubic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What should the nurse assess for with patients with a suprapubic catheter?

A

Color & Clarity of Urine
Intake/Output
Temperate & Comfort
Condition of Insertion site.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Why are catheters irrigated?

A

To cleanse the lumen, and promote patency.

26
Q

You patient has a CBI(Continuous Bladder Irrigation) running. The patient asks why it is necessary to continually irrigate the bladder following their bladder surgery. How would your respond?

A

Irrigation of the bladder helps to remove blood clots, mucous, and other tissue in the bladder.

27
Q

The patient has an irrigation bag running through the catheter to the bladder and draining to the collection bag. Is this a closed irrigation system or an open irrigation system?

A

Closed.

28
Q

The nurse disconnects the catheter tubing from the collection bags and irrigates with a catheter tipped syringe. Is this a closed irrigation system or an open irrigation system?

A

Open

29
Q

What type of bladder irrigation system (open or closed) has a higher incidence of UTI?

A

Open irrigation, related to the disconnection of the catheter and drainage tube.

30
Q

Urinary diversion is a surgical procedure in which the _________ are rerouted from a diseased system to a ______ on the patient’s abdomen.

A

ureters

stoma

31
Q

True -or- False:

Urinary diversion is permanent.

A

False, Urinary diversion may take place to support and promote healing.

32
Q

When is the use of a rectal tube indicated?

A

Patient is bed-bound or immobilized, incontinent of liquid/semi-liquid stool, is at risk for, or already experiencing, skin breakdown and spread of infection.

33
Q

What are the four types of enemas?

A

Cleansing
Saline
Oil Retention
Carminative

34
Q

The nurse explains to the patient that the cleansing enema works by:

A

stimulating peristalsis by irritating the colon and rectum.

35
Q

The nurse explains to the patient that the saline enema works by:

A

drawing water into the colon to stimulate peristalsis and defecation.

36
Q

The nurse explains to the patient that the oil retention enema works by

A

lubricating the stool.

37
Q

The nurse explains to the patient that the carminative enema works to:

A

helping expel flatus.

38
Q

Small volume enemas contain approximately:

A

150ml

39
Q

Large Volume enemas contain approximately:

A

1000ml

40
Q

Define fecal diversion:

A

Redirecting the bowel to the outside of the body through a stoma.

41
Q

A hemoccult test has been ordered for your patient. What is this testing for?

A

Detect microscopic blood in the stool.

42
Q

Eating what types of food can produce a false positive in a hemoccult test.

A

Red meat, turnips, horseradish.

43
Q

What supplements and medications can produce a false positive in a hemoccult test?

A

Iron, Asprin and Anti-Inflammatory drugs.

44
Q

What type of diet is recommended for patients prior to performing the hemoccult test, and why?

A

High Fiber, increases the chances of finding occult blood if a lesion is present.

45
Q

What hormone is primarily responsible for fluid balance control?

A

ADH- Anti-Diuretic Hormone.

46
Q

A patient who has nausea, vomiting, and diarrhea should be monitored closely for what? How is this monitored?

A

Fluid Loss & Dehydration- Decreased output, poor skin turgor, dry mucous membranes.

47
Q

Painful, frequent, and urgent urination may be signs of:

A

Urinary Tract Infection.

48
Q

What are the possible causes of urgency?

A

Inflammation or infection of the urethra, bladder or psychological stress.

49
Q

__% of feces is water.

A

75%

50
Q

What types of medications cause constipation?

A

Iron, Pain Medications.

51
Q

Wha types of medications cause diarrhea?

A

Antibiotics.

52
Q

How far should the indwelling catheter be inserted for a male patient?

A

The catheter is inserted until the bifurcation of the catheter is at the meatus.

53
Q

True of False:

Application of a condom catheter requires sterile technique.

A

False, this is a clean procedure.

54
Q

What considerations are made when catheterizing uncircumcised male patients?

A

Foreskin must be pulled back and cleaned, and replaced over the head of the penis after catheterization.

55
Q

When applying a condom catheter, how much space is left between the endo f the penis and the plastic/rubber connecting tube?

A

1-inch.

56
Q

The nurse has finished applying the condom catheter, disposed of equipment, left the patient comfortable, and washer their hands. What is the next step?

A

Inspect the penis in 30 minutes, and check urine flow.

57
Q

How often are condom catheters changed?

A

Daily.

58
Q

The nurse has removed an indwelling catheter per the physicians orders. She documents the DTV time as 1800. What does DTV mean? What time was the catheter removed?

A

Due to void. 1000.

59
Q

When are rectal tubes contraindicated?

A 
Colon or rectal surgery within the last year.
Rectal or anal injury
Severe rectal or anal stricture.
Rectal or anal Tumor
Severe Hemorrhoid
Fecal Impaction.
60
Q

What does the nurse assess prior to rectal tube insertion?

A

Date of last bowel movement.
Bowel Sounds/Abdominal Distention
Fecal Impaction
Rectal Sphincter Tone

NSG 1101 (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions