Assessment

1. When assessing a client with a GI system disorder, the nurse should check for all of the
following associated symptoms, except:

Heartburn

Chills

Flatus

Eructation

2. When examining the abdomen of a client with GI system disorder, the nurse should
perform all of the following, except:

Percussion

Palpation

Auscultation

Incision

3. When assessing the elimination patterns of a client with GI system disorder, the nurse
should monitor all of the following, except:

Pattern of stools

Laxative used

Olfactory property of stool

Consistency of stools

Assessment

1. Twenty four hours before a barium enema procedure, the client should be put on a:
Low-calorie diet

Salt-restricted diet

Liquid diet

Low-potassium diet

2. A barium enema is performed to assess the:

Gallbladder

Liver

Large colon

Pancreas

3. In regard to barium swallow, laxatives should be given:

During the procedure

Before the procedure only

Before and after the procedure

After the procedure only

Assessment

1. In colonoscopy, bowel prep usually includes:

Telepaque and enema

Anticholinergic drugs and enema

An enema and laxative

Anticholinergic drugs and laxative

2. All of the following drugs are used during endoscopy, except:

Valium

Furosemide

Demerol

Versed

3. Colonoscopy is usually performed to assess the:

Duodenum

Cecum

Ileum

Sigmoid colon

Assessment

1. Prior to a cholecystogram/cholangiogram procedure, the nurse should assess the

client for allergies to:

Peanuts or shellfish

lodine or shellfish

Peanuts or red meat

lodine or red meat

2. This is administered during a cholecystogram/cholangiogram procedure:

Triptafen

Salbutamol

Telepaque

Barium
3. Stool analysis is performed for all of the following purposes, except:

To look for fat

To look for blood in the GI system

To look for bacteria

To assess nutritional intake

Assessment

1. Liver biopsy is best described as:

The insertion of a tube into the liver to rule out liver disease

The removal of liver enzymes to rule out liver disease

The insertion of an endoscope into the liver to rule out liver disease

The removal of liver tissue to rule out liver disease

2. Liver biopsy is usually done under:

Gamma cameras

Endoscopy

Gastroscopy

Fluoroscopy

3. During a liver biopsy, the client should be positioned:

On the right side

On the left side

Lying flat on the bed

Sitting up
Assessment

1. Ascites refers to:

Electrolyte deficiency in the abdomen

The accumulation of water in the abdomen

Fluid and electrolyte deficiencies in the abdomen

The accumulation of fluid and electrolytes in the abdomen

2. Paracentesis refers to:

The removal of fluid accumulated in the peritoneum

The removal of liver tissue

The visual inspection of any cavity of the body

The assessment of the abdominal cavity for bacteria, virus, ova or parasites

3. During a paracentesis procedure, the client should be positioned:

Sitting up with feet resting on a stool

Sitting up with hands on the chest

Lying flat on the bed

In a semi-Fowler's position

Assessment

1. Blood ammonia tests are done to:

Assess intrinsic clotting processes in the liver

Assess the liver's ability to deaminate protein byproducts

Assess extrinsic clotting processes in the liver

Assess for bile duct obstruction

2. A gallbladder ultrasound requires a client to have a/an:

Full bladder

Empty stomach

Full stomach

Empty bladder

3. Gallbladder ultrasound is done to:

Detect liver enlargement

Detect liver cirrhosis

Detect pancreatitis

Detect stones in the gallbladder

Assessment

1. This type of tube is also known as an "intestinal tube":

Miller-Abbot/Anderson tube

Salem sump

Sengstaken-Blakemore tube

Ewald tube

2. According to the video, this is the most frequently used gastrointestinal tube:

Ewald tube

Nasogastric tube

Salem sump
Miller-Abbot/Anderson tube

3. According to the lesson, this type of gastrointestinal tube is frequently used in

emergency situations:

Miller-Abbot/Anderson tube

Ewald tube

Salem sump

Sengstaken-Blakemore tube

Assessment

1. This residual amount shows malabsorption of nasogastric tube feeding:

70 cc

100 cc

10 cc

50 cc

2. Prior to putting anything into a nasogastric tube, the nurse should always check for:

Stomach contents

Residual

Placement

Client's position

3. These feeding tubes do not require checking for placement:

NG tube and G-tube

NG tube and Salem sump

PEG tube and G-tube

Salem sump and PEG tube

Assessment

1. According to the video, the major complication of a dislodged PEG tube is:

Systemic infection

Fungal infection

Viral infection

Parasitical infection

2. In regard to gastric feeding tubes, "PEG" stands for:

Percutaneous Endoscopic Gastric

Permanent Endoscopic Gastric

Percutaneous Endoscopic Gastrostomy

Permanent Endoscopic Gastrostomy

3. All of the following statements about a PEG tube are true, except:

It is non-invasive

It does not require checking for placement

It is placed primarily for long-term feeding needs

It is preferred over gastrostomy tube

Assessment

1. Total Parenteral Nutrition (TPN) refers to:

Intravenous administration of a hypertonic solution of glucose, nitrogen and other
nutrients to achieve tissue synthesis and anabolism

Intravenous administration of a hypotonic solution of sodium, nitrogen and enzymes to

prevent trauma to the stomach lining

Intravenous administration of a hypotonic solution of sodium, nitrogen and enzymes to

promote metabolic processes

Intravenous administration of a hypertonic solution of sodium, iodine and other nutrients

to treat esophageal varices

2. All of the following are stated safety issues in regard to a TPN procedure, except:

Tubing should be changed every 12 hours

It is given in a central line

No piggybacking except for lipids

It contains a high concentration of glucose

3. To prevent bacterial infection during TPN, the tubing should be changed every:

12 hours

48 hours

36 hours

24 hours

Assessment

1. Most specifically, hiatal hernia refers to:

Hernia located directly above the peritoneum

The herniated portion of the stomach through the esophageal hiatus of the diaphragm
Hernia involving only one sidewall of the bowel, which can result in bowel strangulation

The herniated portion through the linea alba above the umbilicus

2. If an anticholinergic drug is administered to a client with hiatal hernia, all of the

following symptoms may occur, except:

Constipation

Urinary retention

Excessive saliva secretion

Visual disturbance

3. All of the following are stated manifestations of hiatal hernia, except:

Heart burn

Chest pain

Jaundice

Dysphagia

Assessment

1. According to the video, a client with chronic gastric ulcer usually experiences pain:

1⁄2-1 hour after meals

11⁄2-1 hour before meals

2-3 hours after meals

2-3 hours before meals

2. According to the lesson, hematemesis is more common than melena in this type of
ulcer:
Chronic duodenal ulcer

Chronic gastric ulcer

Esophageal ulcer

Stress ulcer

3. Hematemesis means:

To vomit blood

Excessive sweating

The feeling of being full even if hungry

To defecate hard stool

Assessment

1. According to the video, H. pylori ulcers are usually treated with:

Butorphanol (Stadol)

Meprobamate (Meprospan)

Bismuth (Pepto-Bismol)

Zopiclone (Lunesta)

2. All of the following are systemic drugs administered to clients with gastric ulcer,
except:

Prilosec

Zantac

Tagamet

Carafate
3. These antacids are usually administered to clients with duodenal or gastric ulcers:

Cetirizine and Loratadine

Amphojel and Janimine

Loratadine and Maalox

Amphojel and Maalox

Assessment

1. In a client with "dumping syndrome", hypoglycemia usually occurs:

25-30 minutes after a meal

5-6 hours after a meal

30-45 minutes after a meal

2-3 hours after a meal

2. In a client with "dumping syndrome", dizziness and diaphoresis are usually

experienced:

1-2 hours after a meal

25-30 minutes after a meal

30-45 minutes after a meal

10-15 minutes after a meal

3. In regard to gastric resection, "dumping syndrome" occurs when:

Ingested food rapidly enters the jejunum, without proper mixing and the normal
digestive process of the duodenum

Ingested food slowly enters the ileum, without proper mixing and the normal digestive
process of the jejunum
Ingested food rapidly enters the ileum, without proper mixing and the normal digestive
process of the jejunum

Ingested food slowly enters the jejunum, without proper mixing and the normal digestive
process of the duodenum

Assessment

1. In regard to gastrointestinal disorders, outpouching of the colon is known as:

Ileostomy

Colostomy

Diverticulitis

Diverticulosis

2. Infected outpouching of the colon is commonly known as:

Ileostomy

Diverticulosis

Colostomy

Diverticulitis

3. Mucosal ulceration of the lower colon and rectum is the pathology of:

Crohn's disease

Duodenal ulcer

Ulcerative colitis

Gastric ulcer

Assessment

1. All of the following are stated symptoms of bowel obstruction, except:

Vomiting

Pain

Abdominal distention

Black, tarry stool

2. All of the following are stated causes of bowel obstruction, except:

Thrombus

Narrowing

Scarring

Tumor

3. All of the following are stated symptoms of bowel obstruction, except:

Liquid stool

Decreased bowel sounds

Decreased urine output

No stool

Assessment

1. The stool of a client with ileostomy is:

Hard

Formed

Tarry

Liquid

2. The stool of a client with colostomy is:

Oily
Watery

Semi-formed to formed

Black and tarry

3. The basic differences between colostomy and ileostomy are:

The frequency and type of exudate

The position on the abdominal wall and the amount of exudate

The position on the abdominal wall and the type of exudate

The position on the abdominal wall and the frequency of exudate

Assessment

1. Jaundice is best characterized by:

Yellowing of the skin and sclera of eyes

Bluish discoloration of the skin

Hyperpigmentation of intertriginous areas

Hyperpigmentation of the abdomen

2. This type of hepatitis can be transmitted by food, fingers, feces, and floods:

Hepatitis Non-A, Non-B

Hepatitis B

Hepatitis C

Hepatitis A

3. According to the lesson, when a client manifests malaise, jaundice, dark urine and
liver tenderness that is caused by a virus transmitted through percutaneous or oral
exposure to blood, the client may be suffering from:
Hepatitis Non-A, Non-B

Hepatitis C

Hepatitis B

Hepatitis A

Assessment

1. All of the following are functions of the liver, except:

Synthesis of clotting factors

Metabolism of hormones

Synthesis of albumin

Regulation of fluids and electrolytes

2. Cirrhosis occurs when:

Blood clots are present

Scar tissue is replaced by cell regrowth

Metabolism of hormones is insufficient

Cells are destroyed and replaced by scar tissue

3. All of the following are functions of the liver, except:

Protein metabolism

Blood storage

Filter action, especially drugs

Fat metabolism through urine production

Assessment

1. In regard to liver cirrhosis, esophageal varices results from:

Portal hypertension and back pressure on the azygos vein

Portal hypotension and back pressure on the azygos vein

Portal hypotension and back pressure on the esophagus

Portal hypertension and back pressure on the esophagus

2. An alcohol-related manifestation of liver cirrhosis in the later stage is called:

Bulimia

PTSD

Delirium tremens

Wernicke-Korsakoff psychosis

3. All of the following are stated manifestations of liver cirrhosis in the later stage,
except:

Clay-colored stools

Dark-colored urine

Dry skin

Painful esophageal varices

Assessment

1. Most specifically, apraxia is:

The inability to perform purposeful movement

A movement problem caused by death of muscle cells and tissues

A movement problem caused by defective fibrillin formation

A movement problem caused by abnormal muscle tremor

2. In hepatic encephalopathy, failure of the liver most specifically causes the:

Degeneration of the brain and central nervous system

Degeneration of the kidney and circulatory system

Degeneration of the intestines and neurovascular system

Degeneration of peripheral tissues and cardiovascular system

3. Asterixis most specifically refers to:

A movement problem caused by abnormal muscle tremor

The inability to perform involuntary and voluntary movements

A movement problem caused by defective fibrillin formation

A movement problem caused by death of muscle cells and tissue

Assessment

1. Spironolactone and furosemide are examples of:

Antibiotics

Narcotics

Diuretics

Neuroleptics

2. In a client with liver cirrhosis, neomycin is administered most specifically to:

Decrease fluid retention

Decrease ammonia levels

Reduce intestinal bacteria

Increase protein levels

3. All of the following are appropriate nursing interventions for liver cirrhosis, except:

Monitor intake and output

Provide a high-fat, low-sodium diet

Measure abdominal girth

Weigh client daily

Assessment

1. This drug should be administered to clients with bleeding esophageal varices:

Pitressin

Clonidine

Amiodarone

Hydralazine

2. In a client with bleeding esophageal varices, vasopressin works by most specifically:

Reducing blood volume depletion

Dilating vessels to decrease bleeding

Reducing peripheral circulation

Constricting vessels to decrease bleeding

3. Before inserting a Sangstaken-Blakemore tube in a client with bleeding esophageal

varices, the nurse should:

Administer vitamin D

Maintain client airway

Have the client assume a fetal position

Assessment
1. Antiemetic PRN is used in clients with gallbladder disease to prevent:

Jaundice

Fat intolerance

Pain

Nausea and vomiting

2. All of the following are stated manifestations of gallbladder disease, except:

Fat intolerance

Left-upper quadrant pain

Nausea and vomiting

Murphy's sign

3. This narcotic drug should not be administered in a client with gallbladder disease:

Tribromoethanol

Butacaine

Vasomax

Morphine

Assessment

1. Steatorrhea is best characterized by:

Formed stools

Watery stools

Fatty stools

Black, tarry stools

2. All of the following are appropriate nursing interventions for a client with pancreatitis,
except:

Administer pancreatic enzymes

Avoid meperidine

Avoid stimulants

Administer anticholinergics and antacids

3. All of the following are possible manifestations of pancreatitis, except:

Murphy's sign

Pleural effusion

Persistent vomiting

Abdominal distention

Assessment

1. Draining large amounts of gastric secretions could indicate all of the following,
except:

Gastric ulceration

Obstruction

Poor gastric emptying

Ileus

2. If there is a possibility that the tube might need to be re-inserted, the nurse should
explain potential complications, such as:

Gastric distention or vomiting

Poor gastric emptying and ulceration

Esophagitis and sinusitis

Obstruction and ileus

3. If the tube was placed to keep the stomach empty during and after surgery,
auscultate all four quadrants of the abdomen to verify that:

Peristalsis is present

Anastalsis is present

Peristalsis is absent

Anastalsis is absent

Assessment

1. Coiling the NG tube around the hands while pulling prevents:

Irritating the nasal mucosa

Aspirating the gastric drainage into the lungs

Spillage of gastric contents

Irritating the esophagus

2. Before removing the NG tube, the nurse should clear the tube of gastric drainage to
prevent all of the following, except:

Irritating the nasal mucosa

Gastric drainage

Irritating the esophagus

Aspirating the gastric drainage into the lungs

3. To prevent damage to esophageal tissue during NG tube removal, the nurse should:
Remove the feeding tube

Remove the safety pin

Disconnect suction

Remove the tape

Assessment

1. Long-term NG tube placement increases the risk of complications, including all of the
following, except:

Sinusitis

Ileus

Esophagitis

Gastric ulceration

2. After tube removal, be especially careful to assess for skin breakdown around the:

Esophagus

Nasopharynx

Nares

Oropharynx

3. If the NG tube was attached to suction or a feeding pump, record the amount of
intake or drainage in the:

Progress report

Kardex

Intake and output record

Nurse's notes

Assessment

1. Prior to removing the NG tube, the nurse should clear out the tube by:

Flushing 10 to 20 cc of air

Flushing 10 to 20 cc of water

Flushing 30 to 50 cc of water

Flushing 30 to 50 cc of air

2. The complications of tube feeding may not appear:

During tube removal

Until after the tube is removed

During tube insertion

Before the tube is inserted

3. Nurses caring for a tube feeding client need to conduct daily assessments of all of
the following, except:

Any additional treatment the client requires

Signs of developing pressure sores from the tube

Condition of the nares

Complaints of pain from the client

Assessment

1. If possible, after the tube feeding the client should remain in a high Fowler's position
for:
45 minutes

1 hour

30 minutes

10 minutes

2. Entral tube feedings are contraindicated in clients with all of the following conditions,
except:

Severe pancreatitis

Diffused peritonitis

Intestinal obstruction

Intractable vomiting

3. To determine the client's tolerance for the tube feeding, the nurse should:

Assess the feeding tube placement

Assess the client for signs of gastric distress

Assess the client's respiratory status

Assess the client's ongoing nutritional status

Assessment

1. To allow gravity to control the flow rate when using intermittent gavage feeding, the
nurse should:

Attach the proximal end of tubing to feeding tube adapter and adjust drip to infuse
over the prescribed time

Attach the distal end of tubing to feeding tube adapter and adjust drip to infuse over
the prescribed time
Attach the distal end of tubing to feeding directly into the feeding bag and adjust drip
to infuse over the prescribed time

Attach the proximal end of tubing to feeding directly into the feeding bag and adjust
drip to infuse over the prescribed time

2. If the residual is greater than 50 to 100 ml, the nurse should hold feeding until the
residual diminishes, to:

Reduce the risk of regurgitation and pulmonary aspiration

Prevent the delay of gastric emptying

Prevent electrolyte imbalance

Reduce the risk of abdominal distention and gas accumulation

3. Delayed gastric emptying indicates:

Absence of anastalsis

Presence of anastalsis

Presence of peristalsis

Absence of peristalsis

Assessment

1. Because of smaller body mass, children under enteral tube feeding are at a higher
risk for all of the following, except:

Fluid overload

Electrolyte imbalance

Dehydration

Intractable vomiting
2. All of the following are possible adverse effects of an enteral tube feeding, except:

Bloating

Nausea

Intractable vomiting

Vomiting

3. When performing an enteral tube feeding, it is important to present the feeding as:

An activity

A procedure

A medication

Meal time

Assessment

1. According to the lesson, unless the client is on fluid restriction, the nurse should be
able to flush the tube after feeding using water in an amount up to:

150 cc

50 cc

100 cc

10 cc

2. If the client's head cannot be elevated during feeding, then it is crucial to:

Lessen the flow rate of the feeding

Ensure that the feeding tube remains in stomach

Turn the head to the side

Elevate the head of the bed

3. All of the following are possible causes of stomach bloating in clients undergoing
enteral tube feeding, except:

A bolus feeding is given too quickly

A presence of peristalsis

A bolus feeding is given cold

Feedings are too closely spaced

Assessment

1. To allow the catheter tip to move freely, the best position for the client is:

Lateral position

Semi-Fowler's position

Supine position

Prone position

2. Gastrointestinal suctioning is used for several reasons, including all of the following,
except:

Allow the GI system to rest and heal

Measure and monitor gastric residual

Decompression of the stomach

Drainage of the stomach

3. To assess for evidence of bleeding or infection and the need for suctioning, the nurse
should monitor gastric contents for all of the following, except:

Clarity
Color

Consistency

Odor

Assessment

1. To provide a suction source when using wall suction, the nurse should:

Plug the machine into the power source

Insert the machine into the suction port

Insert the suction regulator into the suction port

Plug the suction regulator into the power source

2. Intermittent or continuous suctioning is determined by the:

Nares used

Size of the tubing

Suction pressure

Type of tube inserted

3. Single-lumen tubes are used to provide:

Intermittent high pressure

Intermittent low pressure

Continuous high pressure

Continuous low pressure

Assessment

1. The nature and amount of aspirate and drainage should be documented in the:
Nurse's notes

Intake and output record

Progress report

Flowsheet

2. The client needs to know that a soft hissing noise of GI suction device is:

Not normal and an indication the system is not working properly

An indication of effective intervention

Normal and an indication the system is working correctly

Not an indication of effective intervention

3. Gl suctioning is never used as a long-term care option because of the trauma to the:

Esophagus and gastric lining

Trachea and pulmonary tree

Esophagus and pulmonary tree

Trachea and gastric lining

Assessment

1. The tip of the suction catheter becomes plugged. If policy permits, the nurse may:

Irrigate the NG tube with 30 cc of normal saline

Irrigate the NG tube with 30 cc of heparin

Flush the NG tube with 10 cc of water

Flush the NG tube with 10 cc of heparin solution

2. To prevent the catheter from adhering to the stomach wall and causing tissue
damage, the nurse should:

Set the gastric suction on low

Reposition the client frequently

Assess all the connections in the tubing

Gently milk the connecting tubing

3. Fluid in the drainage container does not guarantee that:

The suction regulator is not working properly

The suction is not working properly

The suction regulator is working properly

The suction is working properly

Assessment

1. When applying a condom catheter, the nurse should do all of the following, except:

Assure the client that it is not unusual to get an erection when applying a condom
catheter

Explain the need for the catheter carefully so as not to embarrass client

Instruct the client to make sure that the bag is carried with him at the level of the
bladder if he ambulates

Instruct the client to inform the nurse if irritation occurs

2. Before applying a condom catheter, the nurse should prepare all of the following,
except:

Condom catheter kit with adhesive strip

Basin with warm water and soap

Urinary drainage bag

Water-soluble lubricant

3. Before applying a condom catheter, the nurse should assess all of the following,
except:

The presence of Toileting Self-Care Deficit

The skin integrity around the penis and perineal area, looking for signs of irritation and
skin breakdown

Latex allergies

The amount and pattern of urinary incontinence to determine if the condom catheter is
the best continence method for the client

Assessment

1. When applying a condom catheter, the nurse should:

Apply the double-sided adhesive strip by encircling the base of the client's penis

Apply the double-sided adhesive strip around the tip of the client's penis in a spiral
fashion

Apply the double-sided adhesive strip around the base of the client's penis in a spiral
fashion

Apply the double-sided adhesive strip by encircling the tip of the client's penis

2. When applying a condom catheter, it is preferable to place the client in a:

Lithotomy position

Sims' position

Fowler's position
Supine position

3. When applying a condom catheter, the nurse should:

Position the rolled condom at the proximal portion of the penis and unroll it, covering
the penis and the double-sided strip of adhesive, leaving a 3- to 4-inch space between
the tip of the penis and the end of the condom

Position the rolled condom at the distal portion of the penis and unroll it, covering the
penis and the double-sided strip of adhesive, leaving a 3- to 4-inch space between the
tip of the penis and the end of the condom

Position the rolled condom at the distal portion of the penis and unroll it, covering the
penis and the double-sided strip of adhesive, leaving a 1- to 2-inch space between the
tip of the penis and the end of the condom

Position the rolled condom at the proximal portion of the penis and unroll it, covering
the penis and the double-sided strip of adhesive, leaving a 1- to 2-inch space between
the tip of the penis and the end of the condom

Assessment

1. When applying a condom catheter on a home care client, the nurse should consider
all of the following, except:

The nurse should discuss with the client alternatives to the condom should it need to be
removed

Clients should be taught the signs and symptoms of irritation or skin breakdown

The catheter can be left in place for up to five days at a time

The home caregiver should be instructed on how to clean, use, apply, and remove the
condom catheter

2. When applying a condom catheter on a pediatric client, the nurse should consider
all of the following, except:
The procedure may be best performed by a male staff member

Use of a size appropriate to the child

Diapers may be considered for teenagers and school age children

If output measurements are needed, a condom catheter may be necessary

3. In evaluating the application of a condom catheter, the nurse should have ensured
all of the following, except:

That the client understands the reason for, and cooperates with, the placement and
retention of the condom catheter

That the client does not have any skin irritation from the condom catheter

That the client's condom catheter is in place without leakage or discomfort

That any client teaching or reluctance was recorded

Assessment

1. Wrapping the adhesive of a condom catheter in a tourniquet fashion around the

penis can result in all of the following, except:

Necrosis

Nerve damage

Tissue damage

Improper adhesion

2. When applying a condom catheter, the nurse should consider all of the following,
except:

If the client has excessive hair, it can be quite uncomfortable for the client and may
require partial shaving
It may be necessary to use restraints on an unconscious or confused client

Do not reattach a condom catheter if it falls off as it may cause infection

Use a skin preparation solution if available to remove skin oils

3. After applying a condom catheter, the nurse should inspect it at least every:

12 hours

4 hours

24 hours

2 hours

Assessment

1. Assessing all of the following allows the nurse to plan the procedure with the client's
limitations in mind, except:

If the client has bowel sounds

A history of hemorrhoids, constipation or diverculitis

If the client will be able to hold a side-lying or knee-chest position

If the client will be able to release the enema solution

2. Many different solutions are used for enemas, including all of the following, except:

Soap solutions

Carbonated solutions

Hypertonic solutions

Normal saline

3. Clients should be instructed that lying on the back with knees and hips flexed toward
the chest may:
Make it harder to self-administer an enema

Lessen the intensity of abdominal cramps

Make it easier to self-administer an enema

Worsen the intensity of abdominal cramps

Assessment

1. During the administration of an enema, pointing the enema nozzle toward the
umbilicus positions the nozzle:

Away from the rectal walls

Towards the rectal walls

Towards the rectal sphincter

Away from the rectal sphincter

2. The position that best exposes the anus for administration of an enema is:

Dorsal recumbent position

Supine position

Left-lateral position

Prone position

3. To prepare the enema for use, the caregiver should do all of the following, except:

Remove prepackaged enema from packaging

Perform perianal care

Stand a packaged enema in a basin of warm water to warm the fluid prior to use

Be familiar with any special instructions included with the enema

1. A common concern in the long-term setting is:
Hemorrhoids
Constipation
Diverticulitis
Diarrhea
2. The nurse should especially note in the intake and output record if the amount of fluid
returned is significantly:
Less than the amount infused
The same as the amount infused
More than the amount infused
Unequal to the total fluid returned
3. The only type of enema solution that can be used in infants and children is:
Isotonic solution
Hypertonic solution
Carminative solution
Soap solution

1. All of the following lifestyle changes can prevent constipation, except:

Drink at least 8 glasses of water everyday
Exercise
Increase the amount of fiber in the diet
Bed rest
2. Since many prepackaged enemas are designed to stimulate peristalsis, giving a
prepackaged enema that is cooler than body temperature can cause:
Severe cramping
Diverticulitis
Electrolyte imbalance
Diarrhea
3. Before using an enema to treat constipation, the nurse should consider all of the following,
except:
Oral medication
Increasing fluid intake
Flushing the stool
Suppositories

1. A colostomy is:
An artificial opening created between the kidney and the skin which allows for the drainage of
urine
A stoma that has been constructed by bringing the end of the small intestine out onto the
surface of the skin.
A creation of an artificial external opening into the stomach for nutritional support
An opening surgically created from the ascending, transverse, or descending colon to the
abdominal wall
2. The nurse should instruct the client on pouch application, including:
List of equipment needed
Changes in skin condition to report
Frequency of change
Measuring the pouch
3. To alleviate the problem of obtaining the wrong size equipment, the nurse should:
Measure the dimensions of the cecum prior to obtaining an ostomy appliance system from
central supply
Measure the dimensions of the ileum prior to obtaining an ostomy appliance system from central
supply
Measure the dimensions of the stoma prior to obtaining an ostomy appliance system from
central supply
Measure the dimensions of the colon prior to obtaining an ostomy appliance system from
central supply

1. To prevent contamination of the surrounding environment, if stool accidentally leaks from the
appliance when removed from client's skin, the nurse should:
Tape the wafer edges down with hypoallergenic tape
Remove the current ostomy appliance after emptying pouch of stool
Dispose of the appliance in an appropriate waste container
Cleanse the stoma and skin with warm tap water
2. In order for the wafer to become adherent to skin, the nurse should:
Remove the paper backing from the wafer
Attach a clean pouch to wafer
Tape the wafer edges down with hypoallergenic tape
Cleanse the stoma and skin with warm tap water
3. To prevent stool from leaking underneath the wafer during the application process, the nurse
should:
Remove the current ostomy appliance after emptying pouch of stool
Trace a pattern onto the paper backing of wafer
Preattach the pouch to the wafer
Place a gauze pad over the orifice of the stoma to wick stool

1. The best ostomy appliance that can be used which is adaptable to decreases in hand
dexterity is a/an:
Two-piece appliance
One-piece appliance that is not precut
Closed-end pouch
Mini ostomy pouch
2. Adolescents need careful assessment and intervention to help them adjust to:
Physical disturbances
Changes in ostomy appliances
Changes in body images related to the stoma and appliance
Changes in the condition of the skin
3. All of the following should be documented in the nurse's notes after changing a bowel
diversion ostomy appliance, except:
Assessment of the peristomal skin
Peristomal skin measurements
Color and amount of drainage
Type of ostomy pouch applied

1. If a client who had abdominal perineal surgery with a permanent colostomy for rectal cancer
is not aware of the permanence of the colostomy, given the surgical procedure he recently
underwent, it is possible that:
The client did not understand the purpose of the surgery
The client has not fully recovered from the anesthetic agents used during surgery
The client was not taught about the outcomes of the procedure
The client is experiencing memory loss after the surgery
2. When an ostomy pouch is always full of liquid stool and the pouch has unsnapped from the
wafer several times, the nurse should:
Cleanse the stoma and skin with warm tap water
Increase the frequency of checking and emptying the pouch
Change the pouch from a drainable system to a ostomy pouch
Remove the current ostomy appliance after emptying the pouch of stool
3. Client teaching is easily incorporated into the care of the ostomy by:
Using an ostomy appliance that is intact, comfortable and easy to use
Providing routine ostomy care
Increasing the client's comfort level
Encouraging the client to assist the nurse during the application process

1. This type of large-bore feeding tube is placed surgically by laparoscopy for long-term use:
Nasoduodenal tube
Nasogastric tube
Gastrostomy tube
Percutaneous endoscopic gastrostomy
2. Before each feeding or medication, the nurse should teach the caregiver how to:
Check the client's level of consciousness
Check the client's respiratory status
Check the tube for correct placement
Check the tube for proper movement
3. All of the following are signs and symptoms of inadvertent respiratory placement of a
large-bore feeding tube, except:
Choking
Cyanosis
Retching
Coughing

1. Assessing placement of the feeding tube by auscultation is:

More reliable than checking for air bubbles
More reliable than checking for gastric contents
Less reliable than checking for gastric contents
Less reliable than checking for air bubbles
2. To allow digestion of the formula or assimilation of the medication before testing the gastric
pH, the nurse should:
Wait for 30 minutes
Wait for 5 hours
Wait for 45 minutes
Wait for 1 hour
3. According to the lesson, gastric contents have pH of:
2 to 3
1to 6
1to4
5 to 7

1. The amount of air that should only be injected into a pediatric feeding tube is:
1.0 to 1.5 ml
0.5 to 1.0 ml
1.5 to 2.0 ml
2.5 to 3.0 ml
2. In a home care setting, determine the client's risk for infection by:
Assessing the caregiver's knowledge about the normal range of pH for Gl contents
Assessing the caregiver's ability to maintain the correct placement of the feeding tube
Assessing the sanitation
Assessing the placement of the feeding tube
3. After assessing the placement of the feeding tube, the nurse should document all of the
following in the nurse's notes, except:
The type of tube placed
The pH measurement
Amount of any fluid infused in the stomach
The character of Gl contents

1. To help clients tolerate the tube if it is placed orally or nasally, the nurse may provide:
Tincture of benzoin
Anesthesia
Sedatives
Antiemetic medications
2. A muffled or faint sound of injected air may signal that the tube is in the:
Oropharynx
Stomach
Esophagus
Lungs
3. To obtain an accurate measurement of ph of GI contents, the nurse should plan a schedule
for all of the following, except:
Medications
Checking for GI distention
Feeding
Checking for tube placement

1. If continuous irrigation is ordered, the type of catheter that must be placed is:
Foley catheter
Standard catheter
Three-way catheter
Council tip catheter
2. To assess the effectiveness of the irrigation, the nurse should assess the bladder drainage for all
of the following, except:
Consistency
Color
Odor
Clarity
3. The nurse should explain to the client the reason for the bladder irrigation and the need to
assess for:
Bladder distention or hematuria
Urinary tract infection or hematuria
Bladder distention or bleeding around the meatus
Urinary tract infection or bleeding around the meatus

1. The nurse should connect one port of the Y connector to the drainage port of the retention
catheter, in order to:
Collect the urine and drained irrigant
Instill the irrigant into the closed system
Prevent the irrigant from by-passing the bladder and flowing directly into the drainage bag
Provide a bifurcation for irrigant to instill as well as urine to drain
2. To minimize the client's risk of infection, when connecting the irrigant to the catheter and
drainage system, the nurse should:
Expel all air from the irrigation tubing
Clamp the urinary catheter
Prepare sterile antiseptic swabs
Apply sterile gloves
3. To instill the irrigant into a closed system, the nurse should:
Attach the third port of the Y adapter to the irrigant tubing
Connect another port of the Y adapter to the drainage tubing in the bag
Attach Y adapter to the drainage tubing distal to the irrigation tubing
Connect one port of the Y connector to the drainage port of the retention catheter

1. Children have smaller bladders and there is a high risk of:

Larger amount of debris in the urine
A catheter plugged with mucus or clots
Swelling of tissues in the lower limbs
Obstruction of the lymphatic system
2. Elderly clients' urine/drainage output must be monitored closely for potential blockages or
retention because they may have:
An increased secretion of fluid into the interstitium
A larger amount of debris in their urine
Obstruction of the lymphatic system
Swelling of tissues in the lower limbs
3. The amount of client urine output can be determined by:
Adding the amount of drainage measured and amount of fluid intake
Adding the used irrigant to the drainage total
Subtracting the drainage total from the used irrigant
Subtracting the used irrigant from the drainage total
1. Slowing the irrigation rate could allow clots and debris to build in the bladder or plug the
catheter, leading
to:
Bleeding around the meatus
Bladder distention
Hematuria
Urinary tract infection
2. When irrigating the bladder, the drainage must always be:
Equal or less than the amount instilled
Equal or less than the amount of total fluid intake
Equal or exceed the amount instilled
Equal or exceed the amount of total fluid intake
3. The physician's orders when the nurse reported that Mr. Turner's bladder irrigation is getting
darker were:
An increase in the rate of continuous irrigation and vital signs every 2 hours for the next 8 hours
A decrease in the rate of intermittent irrigation and vital signs every 2 hours for the next 8 hours
A decrease in the rate of continuous irrigation and vital signs every 2 hours for the next 8 hours
An increase in the rate of intermittent irrigation and vital signs every 2 hours for the next 8 hours