NR 224 Fundamentals Final Review |239 Questions and Answers(A+ Solution guide)

hat is the most effective method to prevent the transfer of clostridium difficile (C. Difficile) ? - HAND HYGIENE with soap and water is effective to physically remove C. difficile spores from the hands. (Potter 1092) What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a forced expiration against a closed airway? - Valsalva Manuever *Normal passage of bowels should be painless, passing soft formed stool* Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the Valsalva manuever and MUST avoid straining to pass stool? - Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound (Potter 1089) What is the term for a collection of hardened feces in the rectum that cannot be expelled due to unrelieved constipation? - Fecal Impaction Where does fecal impaction occur in the colon? - Rectum Least formed stool is present in which portion of the digestive tract? - Ascending Colon Most formed stool is present in which portion of the digestive tract? - Descending Colon Which position should the patient be in while administering an enema? - Left Side-Lying or Sim's PositionWhich factors would contribute to stopping enema administration? - If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is felt Which enema solution is the safest for administration because it does NOT create a danger for excess fluid absorption? - Normal Saline [Isotonic Solution] Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk for fluid imbalance? - Hypertonic Solution Which enema solution is considered to be hypotonic and should NOT be repeated because of the risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts of water? - Tap Water [Hypotonic Solution] Which enema solution lubricates the rectum and allows the feces to absorb the oil making them soft and easier to pass? - Oil Retention