Week 8 Urinary And Bowel Elimination And Abdominal Assessment

Question 1

Given primarily to expel flatus

Answer 1

Carminative enema

Question 2

Dark blood in the stool, indication of bleed in upper GI

Answer 2

Occult blood

Question 3

Removes feces with a veriety of solution

1) prevent escape feces during surgery
2) prepare the intestine for certain diagnostic tests
3) removes feces in instances of constipation or impaction

Answer 3

Cleansing enema

Question 4

1) introduces oil or medication into the rectum and sigmoid colon
2) oil rentention acts to soften the feces and lubricate the rectum and anal canal, thus facilitating passage of feces

Answer 4

Retention enema

Question 5

Describe nursing responsibilities associated with a collection of a stool specimen

Answer 5

1) gloves, clean cup, tongue blade
2) place clean cup on paper towel in bathroom
3) using tongue blade collect needed amount of feces from.patients bed pan
4) transfer stool to cup without touching outside surface of cup
5) dispose of tongue blade and seal cup
6) transfer labeled specimen into clean labeled biohazard bag for transport
7) remove gloves and perform hand hygiene

Question 6

Use soapsuds enemas with caution in ______________ and ___________ because they could cause electrolyte imbalance or damage to the intestinal mucosa

Answer 6

Pregnant women and elderly

Question 7

A type of enema that has magnesium, glycerin and water

Answer 7

Carminative- used for gas

Question 8

Low volume enemas include

Answer 8

Sodium phosphate( hypertonic)
Oil rentention 

90-120mL

Question 9

Volume for tap water and soap suds enema

Answer 9

500-1000 mL

Question 10

Position for enema

Answer 10

Left side Sims

Question 11

Volume of liquid for oil rentention and sodium phosphate enema

Answer 11

90-120mL

Question 12

Volume for soap suds

Answer 12

500-1000mL

Question 13

Volume for carminative

Answer 13

180
30mL magnesium
60 mL gycerin
90mL water

Question 14

Enema which takes the longest time to be effective

Answer 14

Oil rentention

Question 15

Fastest acting enema

Answer 15

Soap suds

Question 16

Sodium phosphate enema is contraindicated in what patients

Answer 16

Infants and dehydrated

Question 17

Soap suds enema is used with caution in patients___________

Answer 17

Who are pregnant, and whom are older adults

Question 18

Which type of enema draws fluid into the interstitial space

Answer 18

Tap water

Question 19

Which type of enema would draw fuild into the lumen of the intestine

Answer 19

Sodium phosphate/ hypertonic

Question 20

Use this type of enema with caution when ordered multiple times

Answer 20

Tap water

Question 21

Compare and contrast between cleansing enemas and retention enemas

Answer 21

Cleansing: promote evacuation by stimulation of peristalsis via large volume or local irritation

Oil retention: introduces oil or medication
Acts to soften feces and lubricate the rectum

Question 22

Interventions and rationale when administering a rectal suppository

Answer 22

1) Lubricate rounded end of sup.
2) Lubricate the index finger of the Dom. Hand
3) Ask pt. To take slow deep breaths and relax the anal sphincter
4) retract buttocks with nondominant hand
5) instert sup. Past sphincter along rectal wall
6) ask pt. To lie on side or remain flat for 5 minutes to prevent expulsion

Question 23

Double lumen catheter, large lumen drains urine from the bladder, a second small lumen is used to inflate the balloon near the tip of the catheter.

Answer 23

Foley/ retention/ indwelling catheter

Question 24

Single lumen tube with a small eye or round opening about 1 1/4 centimeters from the insertion tip

Answer 24

Straight catheter

Question 25

Back lying position with feet supported in stirups ; the hips should be inline with the edge of the table

Answer 25

Lithotomy position

Question 26

Urine specimen collected when urine culture is ordered to identify microorganisms causing UTI

Answer 26

Clean catch urine

Question 27

Determines the presence of microorganisms, the type of organism, and the antibiotics to use to destroy the microorganism

Answer 27

Urine for culture and sensitivity ( C& S)

Question 28

Used to determine urine composition and possible abnormal components or infection

Answer 28

Urinalysis

Question 29

Midstream catch is used for?

Answer 29

Urinalysis or to detect infection

Question 30

Clean catch is used for

Answer 30

UTI

Question 31

Describe timed urine specimen collection

Answer 31

Used to analyze kidney function.

1) place alerts on pt. Door
2) clean technique
3) specimen must be free of paper and feces
4) have patient void, discard this urine and begin 24 hour collection period
5) number specimen sequentially
6) have pt. Void five minutes before end of 24 he period
7) check to see if urine should be refrigerated
8) keep outside of containers clean
9) transport in labeled plastic bag

Question 32

CAUTI

Answer 32

Catheter associated UTI

Question 33

Cath. Care q ______ hours as minimal standard of care

Answer 33

8 hours

Question 34

Empty drainage bag when _____ full

Answer 34

1/2 full

Question 35

Normal bowel sounds

Answer 35

5-30/min irregular

Question 36

Dullness upon abdominal percussion is generally heard over _______

Answer 36

Organs

Question 37

When percussing the abdomen the right costal margin abdominal tympany should change to dullness over the border of the _______

Answer 37

Liver

Question 38

When documenting a patients emesis what characteristics should be included?

Answer 38

Color
Odor
Volume
Duration

Question 39

After applying pressure at a site away from the area of abdominal pain
, The nurse quickly lifts and removes the hand from the clients abdomen, pain upon realease of the pressure is reffered to as _________

Answer 39

Rebound pain

Rebound pain, and involuntary rigidity are signs that should be reported to the HCP