Review Practice Exercise 2

Exam Review

Practice Exercise 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy

We are excited to announce the release of a NEW VERSION OF THE SYSTEM! To benefit from the latest features, improvements, and component updates, please switch to the new system as soon as possible.

Visit Latest Version

Total Questions : 4

Showing 4 questions, Sign in for more

Question 1:

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?

A. Oil retention B. Return flow C. High, large volume D. Low, small volume

Answer and Explanation

Choice A:

Oil retention: These are used specifically to lubricate and soften a fecal impaction. They do not provide the washing action needed to clear the entire colon wall for a clear camera view.

Choice B:

Return flow: Also known as a Harris flush, these move 100–200 mL of fluid in and out of the rectum to stimulate the passing of gas (flatus). It is a localized treatment for distension, not a cleansing prep.

Choice C:

High, large-volume enemas are cleansing enemas but are not typically used before colonoscopy because they can be uncomfortable and less practical. Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used

Choice D:

Low, small-volume enemas often commercially prepared, e.g., Fleet enema are commonly prescribed before diagnostic procedures like colonoscopy to cleanse the bowel effectively and safely.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 2:

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

A. Prepare to irrigate the colostomy. B. After assessing the stoma and surrounding skin, notify the surgeon. C. Assess bowel sounds and administer antiemetic. D. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

Answer and Explanation

Choice A:

Prepare to irrigate the colostomy: Irrigation is a procedure used to train a sigmoid colostomy or to treat constipation. It should never be done on a brand-new stoma without a specific surgeon's order, as it could cause trauma or perforation to the fresh surgical site.

Choice B:

After assessing the stoma and surrounding skin, notify the surgeon: A client who is one-week post-op with no bowel movement and nausea is exhibiting classic signs of a postoperative ileus or a bowel obstruction. This is a potential surgical complication. The nurse must first perform a focused assessment (looking for stoma color and skin integrity) and then immediately notify the surgeon of the possible obstruction.

Choice C:

Assess bowel sounds and administer antiemetic: While assessing bowel sounds is good, simply giving an antiemetic mask the symptoms of a serious complication (obstruction). You cannot treat the nausea without addressing the reason why the patient is nauseous.

Choice D:

Administer a bulk-forming laxative: Giving a laxative to a patient with a suspected bowel obstruction is dangerous. If there is a physical blockage, adding bulk and stimulating the gut can lead to increased pressure, pain, and potential bowel rupture.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 3:

A nurse is caring for a client with intestinal obstruction. During removal of a fecal impaction, which of the following could occur because of vagal stimulation?

A. Bradycardia B. Atelectasis C. Tachycardia D. Cardiac tamponade

Answer and Explanation

Choice A:

Bradycardia: The rectum is richly supplied with parasympathetic nerve endings. Digital stimulation during the removal of a fecal impaction can stimulate the vagus nerve. Because the vagus nerve exerts an inhibitory effect on the heart, overstimulation results in a sudden drop-in heart rate and potentially a drop in blood pressure (syncope).

Choice B:

Atelectasis: This refers to the collapse of alveoli in the lungs. While it is a common postoperative complication due to shallow breathing, it is not physiologically linked to the stimulation of the vagus nerve in the rectum.

Choice C:

Tachycardia: This is an increased heart rate. Vagal stimulation produces the opposite effect (the parasympathetic response), which slows the heart rate down rather than speeding it up.

Choice D:

Cardiac tamponade: This is a life-threatening condition where fluid builds up in the pericardial sac, compressing the heart. It is typically caused by trauma or disease, not by digital rectal stimulation.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 4:

A nurse is caring for a client with fecal incontinence. Which nursing diagnoses are most applicable? Select all that apply

A. Bowel Incontinence B. Risk for Deficient Fluid Volume C. Disturbed Body Image D. Social Isolation E. Risk for Impaired Skin Integrity

Answer and Explanation

Choice A:

Bowel Incontinence: This is the primary problem. Fecal incontinence is defined as the involuntary passage of stool, which directly supports this nursing diagnosis as the priority.

Choice B:

Risk for Deficient Fluid Volume: While diarrhea can lead to fluid loss, fecal incontinence itself is a matter of control, not necessarily high-volume output. Unless the client has severe, watery diarrhea causing the incontinence, they are generally not at high risk for systemic fluid volume deficit.

Choice C:

Disturbed Body Image: Incontinence is often viewed as a loss of a basic adult function. Clients may feel unclean or ashamed of their body's inability to control elimination, which significantly impacts their self-perception and body image.

Choice D:

Social Isolation: The fear of having an accident in public, combined with concerns about odors, often leads clients to stay home and avoid social gatherings, resulting in withdrawal and isolation.

Choice E:

Risk for Impaired Skin Integrity: Fecal matter contains enzymes and bacteria that are highly irritating to the skin. Constant or frequent exposure to moisture and stool leads to skin breakdown, maceration, and incontinence-associated dermatitis (IAD).

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Sign Up or Login to view all the 4 Questions on this Exam

Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.

Nursing Offer

Upgrade your membership - 15% off

20,000+ questions
to help you excel in your exams.
Exams & Tests
20+ Exit exams & 100+ Test Banks.
Video tutorials
to enhance your learning
Comprehensive study guides
to support your exam preparation.

Get Your Offer Today

Exam Review

Practice Exercise 2 Share this Share This Link Share on social media Facebook Messager WhatsApp Share URL Copy Close

Total Questions : 4

Sign Up or Login to view all the 4 Questions on this Exam

Practice Exercise 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy