Nokea
The nurse administers an enema to a patient as ordered. What should be documented?
- A. Date
- B. Time
- C. Type and volume of enema
- D. Temperature of solution
- E. Characteristics of results
- F. How patient tolerates procedure
Correct Answer: A,B,C,D,E,F
Rationale: Following an enema date, time, type and volume of enema, temperature of solution, characteristics of results and how patient tolerated procedure should all be documented.
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____ is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem especially among older adults.
Correct Answer: Incontinence
Rationale: Incontinence is the inability to control urine or bowel elimination. It can be a psychologically distressing and socially disruptive problem, especially among older adults.
A ____ is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
Correct Answer: urostomy
Rationale: A urostomy is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
When explaining the difference between a colostomy and an ileostomy the nurse explains which of the following about an ileostomy?
- A. It is always permanent.
- B. It drains semiliquid stool.
- C. It has a much larger stoma.
- D. It does not need a pouch.
Correct Answer: B
Rationale: The ileostomy is higher in the GI tract and drains semiliquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch.
During insertion of a Foley catheter the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
- A. Withdraw the catheter.
- B. Ask the patient to bear down.
- C. Continue to inflate the balloon.
- D. Advance the catheter into the bladder.
Correct Answer: D
Rationale: Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled?
- A. At least every hour
- B. At patients request
- C. Before each meal
- D. At bedtime
- E. Upon waking up in morning
Correct Answer: C,D,E
Rationale: Typical voiding times are upon rising, before each meal, and at bedtime. When initiating bladder training the nurse should assist the patient to void as scheduled, check the patient for wetness periodically, and remind or assist the patient to the toilet as scheduled.