RNSG 1105 CORE MAIN QUESTIONS AND ANSWERS
SET A+
✔✔What are the reasons for administering an enema? - ✔✔1. promote defecation by
peristalsis
2. prevent involuntary escape of fecal material during surgical procedures and childbirth
3. promote visualization of the bowel when an x-ray or exam is to be performed
4. bowel training
✔✔Cleansing enema - ✔✔Evacuate feces from the colon by infusing large volumes of
fluid or irritation of bowel mucosa
✔✔Tap Water/Hypotonic enema - ✔✔water flows out of bowel into interstitial tissues
which have higher osmotic pressure; distends intestine, increases peristalsis and
softens stool before significant amounts of fluid are absorbed
✔✔Hypotonic enema safety alert - ✔✔should not be repeated more than three times
due to water toxicity, circulatory overload, fluid and electrolyte imbalance, heart failure
✔✔Isotonic/Normal Saline enema - ✔✔equal concentration on both sides of the
membrane making it the safest type; distends intestine, increases peristalsis and
softens stool
✔✔Isotonic enema adverse effects - ✔✔fluid and electrolyte imbalance, sodium
retention
✔✔Low volume/hypertonic enema - ✔✔draws water out of interstitial tissues into the
colon which has higher osmotic pressure; distends intestine, irritates intestinal mucosa
to stimulate defecation reflex
✔✔Hypertonic enema safety alerts - ✔✔sodium retention; not for infants or patients with
vomiting, diarrhea (dehydrated)
, ✔✔Soapsuds enema - ✔✔causes intestinal irritation or stimulates peristalsis
✔✔Oil retention enema - ✔✔must remain in colon for prolonged period of time; feces
absorb the oil and become softer and easier to pass; used mainly when patient has an
impaction
✔✔Digital removal of stool - ✔✔if impacted stool cannot be expelled voluntarily and oil
retention enema fails to break up the mass, then the impaction must be broken up
manually
✔✔Complications of digital removal - ✔✔vagal stimulation - bradycardia, flushing
irritation of rectal mucosa
✔✔What are the guidelines for measuring vital signs? - ✔✔Select appropriate
equipment
Know the baseline vital signs for the pt and meds they are taking that may affect vital
signs
Consider environmental factors
Take vital signs using an organized systematic approach
Analyze results, determine significant findings, document vital signs, communicate
concerning findings
✔✔ Temperature Range for adult - ✔✔96.8-100.4 degrees F
✔✔Pulse Range for adult - ✔✔60-100 bpm
✔✔Respiration range for adult - ✔✔12-20 breaths/min
✔✔Blood Pressure Range for adult - ✔✔120/80
✔✔O2 Saturation - ✔✔>= 95%
✔✔When to Measure vital signs - ✔✔on admission
routine schedule based on facility policy or HCP order
change in pt condition
before and after: admin of meds that affect respiratory, cardiovascular or temperature-
control function and physical activity as appropriate
before,during, and after: surgery or invasive dx procedures and blood product
transfusions
✔✔Hypothalamus decreases temperature by - ✔✔vasodilation, sweating, and inhibition
of heat production
SET A+
✔✔What are the reasons for administering an enema? - ✔✔1. promote defecation by
peristalsis
2. prevent involuntary escape of fecal material during surgical procedures and childbirth
3. promote visualization of the bowel when an x-ray or exam is to be performed
4. bowel training
✔✔Cleansing enema - ✔✔Evacuate feces from the colon by infusing large volumes of
fluid or irritation of bowel mucosa
✔✔Tap Water/Hypotonic enema - ✔✔water flows out of bowel into interstitial tissues
which have higher osmotic pressure; distends intestine, increases peristalsis and
softens stool before significant amounts of fluid are absorbed
✔✔Hypotonic enema safety alert - ✔✔should not be repeated more than three times
due to water toxicity, circulatory overload, fluid and electrolyte imbalance, heart failure
✔✔Isotonic/Normal Saline enema - ✔✔equal concentration on both sides of the
membrane making it the safest type; distends intestine, increases peristalsis and
softens stool
✔✔Isotonic enema adverse effects - ✔✔fluid and electrolyte imbalance, sodium
retention
✔✔Low volume/hypertonic enema - ✔✔draws water out of interstitial tissues into the
colon which has higher osmotic pressure; distends intestine, irritates intestinal mucosa
to stimulate defecation reflex
✔✔Hypertonic enema safety alerts - ✔✔sodium retention; not for infants or patients with
vomiting, diarrhea (dehydrated)
, ✔✔Soapsuds enema - ✔✔causes intestinal irritation or stimulates peristalsis
✔✔Oil retention enema - ✔✔must remain in colon for prolonged period of time; feces
absorb the oil and become softer and easier to pass; used mainly when patient has an
impaction
✔✔Digital removal of stool - ✔✔if impacted stool cannot be expelled voluntarily and oil
retention enema fails to break up the mass, then the impaction must be broken up
manually
✔✔Complications of digital removal - ✔✔vagal stimulation - bradycardia, flushing
irritation of rectal mucosa
✔✔What are the guidelines for measuring vital signs? - ✔✔Select appropriate
equipment
Know the baseline vital signs for the pt and meds they are taking that may affect vital
signs
Consider environmental factors
Take vital signs using an organized systematic approach
Analyze results, determine significant findings, document vital signs, communicate
concerning findings
✔✔ Temperature Range for adult - ✔✔96.8-100.4 degrees F
✔✔Pulse Range for adult - ✔✔60-100 bpm
✔✔Respiration range for adult - ✔✔12-20 breaths/min
✔✔Blood Pressure Range for adult - ✔✔120/80
✔✔O2 Saturation - ✔✔>= 95%
✔✔When to Measure vital signs - ✔✔on admission
routine schedule based on facility policy or HCP order
change in pt condition
before and after: admin of meds that affect respiratory, cardiovascular or temperature-
control function and physical activity as appropriate
before,during, and after: surgery or invasive dx procedures and blood product
transfusions
✔✔Hypothalamus decreases temperature by - ✔✔vasodilation, sweating, and inhibition
of heat production
