1 >>The client is undergoing diagnostic tests for fecalincontinence. You would expect to prepare the client forwhich of the following tests?Select all that apply. ?
- (A) Ultrasonography.
- (B) Electromyography.
- (C) Colonoscopy.
- (D) all the above
2 >>The client is scheduled for surgery in the morning for anileostomy. He asks you what to expect when he returnsfrom surgery. Your best response is ?
- (A) “You will need to ask the physician, I can’ttell you.”
- (B) “You will have an opening through the abdominalwall where the stool will pass into a bag.”
- (C) “You will have a drain in place from the abdominalincision until bowel function returns.”
- (D) “You will have a catheter inserted into the colon untilthe colon has healed.”
3 >>One of the major differences in care of a client with acolostomy and one with an ileostomy is ?
- (A) The stool of the ileostomy is liquid to semisoft, whichrequires increased fluid intake.
- (B) Only the client with an ileostomy will require the useof a colostomy bag.
- (C) The ileostomy is usually able to be reversed when thedisease process heals.
- (D) There are usually no dietary restrictions with eitherclient.
4 >>Just before removing a fecal impaction, the nurse ?
- (A) Obtains a consent form for the procedure.
- (B) Infuses at least 500 mL of fluid through a rectal tubeinto the lower colon.
- (C) Obtains baseline pulse and blood pressure.
- (D) Gives the client a laxative to assist with the fecalremoval
5 >>The client requires a rectal suppository. Which of thefollowing actions is appropriate when inserting thesuppository? ?
- (A) Ask the client to bear down when you insert thesuppository just beyond the external sphincter.
- (B) Place the flat end of the suppository into the externalsphincter.
- (C) Insert the suppository into the fecal material if at allpossible.
- (D) Place the pointed end of the suppository 3-4 in.beyond the internal sphincter.
6 >>Contraindications for use of the Bowel ManagementSystem includeSelect all that apply. ?
- (A) Recent sphincter reconstruction.
- (B) Impacted or formed stool.
- (C) Severe strictures of distal rectal or anal canal.
- (D) all the above
7 >>Place nursing actions in order they are to be carried outwhen inserting the BMS system. ?
- (A) Gently tug and re-coil catheter to”seal” retentioncuff.
- (B) Fill syringe with 35-40 mL of lukewarm water andinsert into retention cuff using blue connector.
- (C) Confirm pilot balloon is fully collapsed.
- (D) BCA
8 >>The client has an enema ordered before surgery. Whichone of the following nursing actions will you performwhen administering a large volume enema? ?
- (A) Place client on right side in Sims’ position.
- (B) Instruct the client to take in a slow deep breath andinsert tubing 3-4 in.
- (C) Raise height of enema solution to the level of theclient’s shoulder.
- (D) Instill solution over 5 to 10 minutes.
9 >>The student nurse has been instructed to teach the clientand family the application procedure for a fecal ostomypouch. In reviewing the skill, identify which action wouldnot be considered appropriate for applying a pouch. ?
- (A) Remove old pouch by pushing against skin as you pullbacking from skin.
- (B) Cleanse skin and stoma with warm water andgenerous amount of soap.
- (C) Cut new pouch at least 1/8 in. larger than stomawithout pushing on edges.
- (D) Apply ring of skin barrier paste to opening on pouch.
10 >>The student nurse is preparing to begin the leadership componentof the nursing program. The student remembersthat the appropriate delegation of nursing skills includes ?
- (A) Assigning the nursing assistant to complete a fecalimpaction removal on an elderly client.
- (B) Determining that the unlicensed assistive personnelcannot be assigned to care for a client requiring a tapwater enema.
- (C) Asking the RN team leader to administer acarminative enema to the client.
- (D) Assigning the LVN to develop an ileostomy teachingplan for the client and family.
11 >>Fever is an elevation of body temperature due to ?
- (A) Cytokine influence on the hypothalamus.
- (B) Injury to the hypothalamus.
- (C) Dehydration.
- (D) Environmental extremes.
12 >>The most effective method to reduce fever is the use of ?
- (A) Tepid sponging.
- (B) A cooling blanket.
- (C) Antipyretic medication.
- (D) Cool packs to axillae and groin.
13 >>The effect of shivering in response to externalcryotherapy used in the febrile client is ?
- (A) Enhanced body temperature cooling.
- (B) Reduced metabolic rate.
- (C) Increased heat production.
- (D) Increased pyrogen production.
14 >>Most hospitals control facility water to be a maximumtemperature of ?
- (A) 95°F.
- (B) 100°F.
- (C) 110°F.
- (D) 120°F.
15 >>The surgical client wears a head covering to prevent heatloss by ?
- (A) Radiation.
- (B) Evaporation.
- (C) Convection.
- (D) Conduction.
16 >>Which of the following fluids is preferred to rehydrate anover-heated dehydrated client? ?
- (A) Water.
- (B) Intravenous dextrose in water.
- (C) Sport drink.
- (D) NONE
17 >>Expected effects of local cold (cryo) therapy includeSelect all that apply. ?
- (A) Flushing.
- (B) Anesthesia.
- (C) Numbness.
- (D) All the above
18 >>After a sitz bath, the client should be monitored forpossible ?
- (A) Orthostatic hypotension.
- (B) Perineal fungal infection.
- (C) Increased vaginal bleeding.
- (D) Exacerbation of hemorrhoid discomfort.
19 >>Cold applications to injured joints should be of shortduration because ?
- (A) Reactive vasodilation may occur.
- (B) Joints become less flexible with cold application.
- (C) Bleeding may be induced.
- (D) Injury to superficial nerves can occur.
20 >>Heat therapies are contraindicated for areas withcirculatory insufficiency because heat ?
- (A) Increases tissue need for oxygen.
- (B) Decreases metabolic rate thereby increasingischemia.
- (C) Promotes inflammation.
- (D) Decreases sensation and increases risk for injury.