NR224 Fundamentals Final Review Exam with Questions and 100% Accurate Answers – Score 98%
What is the most effective method to prevent the transfer
... [Show More] of clostridium difficile (C. Difficile) ? ANSWER HAND HYGIENE with soap and water is effective to physically remove C. difficile spores from the hands. (Potter 1092)
What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a forced expiration against a closed airway? ANSWER Valsalva Manuever
*Normal passage of bowels should be painless, passing soft formed stool*
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the Valsalva manuever and MUST avoid straining to pass stool? ANSWER Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound
(Potter 1089)
What is the term for a collection of hardened feces in the rectum that cannot be expelled due to unrelieved constipation? ANSWER Fecal Impaction
Where does fecal impaction occur in the colon? ANSWER Rectum
Least formed stool is present in which portion of the digestive tract? ANSWER Ascending Colon
Most formed stool is present in which portion of the digestive tract? ANSWER Descending Colon
Which position should the patient be in while administering an enema? ANSWER Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration? ANSWER If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is felt
Which enema solution is the safest for administration because it does NOT create a danger for excess fluid absorption? ANSWER Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk for fluid imbalance? ANSWER Hypertonic Solution
Which enema solution is considered to be hypotonic and should NOT be repeated because of the risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts of water? ANSWER Tap Water [Hypotonic Solution]
Which enema solution lubricates the rectum and allows the feces to absorb the oil making them soft and easier to pass? ANSWER Oil Retention [Show Less]