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NUR 235 EXAM 2
NUR 235 EXAM 2
NUR 235 Exam 2 Actual Questions and Answers Latest Version
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations?
- the duration of the procedure
- 10 to 15 min
- until the client feels the urge to defecate
- at least 30 min -Correct Answer ✔d) at least 30 min
a nurse is prepapring an adult client for an enema. the nurse should assist the client into which of the following position?
- prone
- dorsal recumbent
- right lateral with both knees at chest
- left lateral with the right leg flexed -Correct Answer ✔d) left lateral with the right leg
flexed
(makes it easier for enema solution to flow by gravity into the sigmoid and descending colon, flexed leg promotes exposure of anus for rectal tube insertion)
a client who is postoperative is experiencing abdominal distention and is having difficult expelling flatus. the nurse should expect the provider to prescribe which of the following types of enemas?
- cleaning
- return flow
- medicated
- oil-retention -Correct Answer ✔b) return flow
expel flatus, stimulate peristalsis, and relieve abdominal distention
a nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. which of the following actions should the nurse take?
- place the client in the dorsal recumbent position on a bedpan
- administer the enema while the client sits on the toilet
- administer an antidiarrheal medication 3 hr prior to the enema
NUR 235 EXAM 2
NUR 235 EXAM 2
- instill 200 mL of fluid over an hour at 15-min intervals -Correct Answer ✔a) place the
client in the dorsal recumbent position on a bedpan
a nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. to which of the following lengths should the nurse insert the rectal tube?
- 2.5 cm to 3.75 cm (1 to 1.5 in)
- 5 cm to 7.5 cm (2-3 in)
- 7.5 cm to 10 com (3-4 in)
- 10 cm to 12.5 cm (4-5 in) -Correct Answer ✔c) 7.5 cm to 10 com (3-4 in)
when a nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following actions should the nurse take?
- measure the clients vital signs
- notify the primary care provider
- lower the enema fluid container
- stop the enema instillation -Correct Answer ✔c) lower the enema fluid container
a nurse is administering a return-flow to a client. after instilling 100mL of enema fluid, which of the following actions should the nurse take?
- instruct the cleint to retain the fluid
- lower the container to allow the solution to flow back out
- help the client to the toilet or bedside commode
- wait 5 min and instill another 100 mL of fluid -Correct Answer ✔b) lower the container
to allow the solution to flow back out
(return flow enemas involve moving 100-200 mL in and out of rectum. after instilling the solution, the nurse lowers the container to allow the solution to flow back in and out)
a nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. which of the following action should the nurse take?
- warm the enema solution prior to instillation
- prepare 1500 mL of enema fluid
- use tap water as the enema fluid
- hang the enema container 24 inches above the anus -Correct Answer ✔a) warm the
enema solution prior to instillation
(cold fluid can cause cramping, too hot can injure intestinal membrane)
which of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallow?
NUR 235 EXAM 2
NUR 235 EXAM 2
- auscultate the client's lungs
- place the tip of a tongue depressor on the client's posterior tongue
- inspect the client's uvula and soft palate with a penlight
- place fingers on the clients throat at the level of the larynx and ask the client to
swallow -Correct Answer ✔a) auscultate the client's lungs
silent aspirations are common complications of swallowing impairment
a nurse is reviewing a client's lab values. which of the following information is correct regarding albumin levels and nutritional status?
- albumin level is a poor short term indicator of protein status
- hydration status does not affect a client's albumin level
- an albumin level of 3.2 d/dL is within the expected reference range
- albumin level is calculated by keeping a 24-hr record of protein intake -Correct
Answer ✔a) albumin level is a poor short term indicator of protein status
what is the excretion of waste products; passage of stool through the intestinal tract or urine through the urinary tract? -Correct Answer ✔elimination
positive consequences of elimination? -Correct Answer ✔regular passage of soft formed stool
passage of clear light yellow urine
normal urinalysis
balanced intake of fluids in and out
negative consequences of elimination -Correct Answer ✔incontinence, retention, discomfort
interrelated consequences of elimination (5) -Correct Answer ✔nutrition cognition fluid and electrolytes mobility acid-base balance
be able to identify the organs of the abdominal cavity -Correct Answer ✔stomach
small and large intestine
liver
NUR 235 EXAM 2
NUR 235 EXAM 2
gallbladder
pancreas
spleen
kidneys
ureters
bladder
adrenal glands
major vessels
in women: uterus, fallopian tubes, and ovaries
be able to understand how the abdomen is divided into four quadrants and which organs are located in what quadrant -Correct Answer ✔upper right quadrant, upper left quadrant, lower right quadrant, lower left quadrant
what organs are located in the upper right quadrant? -Correct Answer ✔liver
transverse colon
what organs are located in the upper left quadrant? -Correct Answer ✔stomach
what organs are located in the lower right quadrant? -Correct Answer ✔ascending colon
what organs are located in the lower left quadrant? -Correct Answer ✔sigmoid colon
abdominal history: problem-based history symptoms -Correct Answer ✔abdominal pain (consider reproductive)
nausea/vomiting
indigestion
change in bowel habit
problems with urination
steps of an abdominal assessment -Correct Answer ✔1) inspection
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