NSO Nur 204 Exam 4
During a routine physical, a 50-year-old client asks why a stool specimen for occult blood testing was prescribed. Which response would the nurse utilize?
''Starting at your age, this test is performed routinely as part of an assessment for colon cancer'' The primary reason for this is that it is apart of a routine examination for colon cancer in any client over the age of 40 years. Age, family hx of polyps, and a positive finding after a digital rectal exam are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test)
A RN is teaching a nursing student about the proper technique of an abdominal assessment. Which order of assessment indicates effective learning?
1. I will inspect the surface motion of the abdomen 2. I will note the position of the umbilicus 3. I will assess for bowel motility by auscultation 4. I will palpate to assess for any abdominal tenderness
A hospitalized client is scheduled to have a sigmoidoscopy. Which action would the nurse perform before the procedure?
Administering a fleet enema 1 hour before the procedure Rationale: To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A fleet of tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.
A client has surgery for the creation of a colostomy. Postoperatively, which color would the nurse expect a viable stoma to be?
BRICK RED rationale: Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion. Light gray is indicative of poor tissue. Dark purple indicates inadequate perfusion.
What measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence?
Check the client's buttocks at least every 2 hours and clean after incontinence Note: making sure patient knows where the call light is is not efficient enough especially bc the patient is confused
What information would the nurse provide a client with a new colostomy about managing the appliance?
Cut opening 1/8 - 1/16 inch larger than stoma Rationale: The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8 - 1/16 inchlarger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powderis used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.
Which factor would a nurse assess for a client reporting constipation?
Diet, fluid intake, use of laxatives, date of last bowel movement, use of opioid pain medications
To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor?
Fluid and electrolyte balance
The client reports abdominal cramping while undergoing a soapsuds enema. What action would the nurse take? a) immediately stop the infusion b) lower the height of the enema bag c) Advance the enema tubing 2 to 3 inches (5 -7.5cm) d) clamp the tube for 2 minutes and then restart the infusion
Lower the height of the enema bag Rational: abdominal cramping during a soapsuds enema may be due too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.
What finding would the nurse document as normal for a second, postabdominnoperineal resection stoma?
Moist, red, and raised above the skin surface
