NSG203 Exam 2 Latest Update
A nurse who is administering a return-flow enema to a patient should instill 100 mL of
enema fluid and then....
A. instruct the patient to retain the fluid
B. lower the container to allow the solution to flow back out
C. help the patient to the toilet or beside commode
D. wait 5 min and instill another 100 mL of fluid - Answer B. lower the container to allow
the solution to flow back out
A nurse is administering an enema medication with sodium polystyrene sulfonate
(Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert
the tip of the rectal tube...
A. 2.5-3.75 cm (1-1.5 in)
B. 5-7.5 cm (2-3 in)
C. 7.5-10 cm (3-4 in)
D. 10-12.5 cm (4-5 in) - Answer C. 7.5-10 cm (3-4 in)
A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal
incontinence due to poor sphincter control and is unlikely to retain the enema solution.
Which of the following interventions is appropriate for this patient?
A. Place the patient in the dorsal recumbent position on a bedpan
B. Administer the enema while the patient sits on the toilet
C. Administer an antidiarrheal mediation 3hr prior to the enema
D. Instill 200mL of fluid at 15-minu intervals times four - Answer A. Place the patient in
the dorsal recumbent position on a bedpan
A nurse is preparing to administer an oil-retention enema to a patient who has
constipation. The nurse explains that the patient should try to retain the instilled oil for
A. as long as it takes to complete the procedure
B. about 10-15 minutes
C. until the next time he feels the urge to defecate
D. at least 30 min, but preferably as long as he can - Answer D. at least 30 min, but
preferably as long as he can
,While a nurse is administering a cleansing enema, the patient reports abdominal
cramping. Which of the following is the appropriate intervention?
A. measure the patient's vital signs
B. notify the PCP
C. lower the enema fluid container
D. stop the enema instillation - Answer C. lower the enema fluid container
A patient who is Post Op is experiencing abdominal distention and is having difficulty
expelling flatus. The nurse should anticipate receiving and order from the provider for
which of the following types of enemas?
A. Cleansing
B. Return-flow
C. Medicated
D. Oil-retention - Answer B. Return-flow
A nurse is preparing to administer the first of two large-volume, cleansing enemas
prescribed for a patient in preparation for a diagnostic procedure. Which of the
following is an appropriate step in the procedure?
A. warm the enema solution prior to instillation
B. prepare 1500 mL of enema fluid
C. use tap water as the enema fluid
D. hang the enema container 24 inches above the anus - Answer A. warm the enema
solution prior to instillation
A nurse is preparing an older adult patient for an enema. The nurse should assist the
patient to which of the following positions?
A. prone
B. dorsal recumbent
C. right lateral with both knees at chest
D. left lateral with the right leg flexed - Answer D. left lateral with the right leg flexed
A nurse is applying a condom catheter for an older adult patient who is uncircumcised.
Which of the following is an appropriate step in this procedure?
A. stretching the catheter along the length of the penis
, B. Securing the catheter with adhesive tape
C. Leaving a space between the penis and catheter's tip
D. repositioning the foreskin after application - Answer C. Leaving a space between the
penis and catheter's tip
A nurse is likely to receive an order for urinary catheterization of a newly admitted
patient who...
A. has a persistent UTI
B. has urge incontinence
C. is in the ICU for a GI bleed
D. is incontinent due to cognitive decline - Answer C. is in the ICU for a GI bleed
When providing perineal care for a female patient who has an indwelling urinary
catheter, which of the following areas should the nurse cleanse last?
A. the urethral meatus
B. the labia minora
C. the perineum
D. the anus - Answer D. the anus
A nurse who is preparing to insert a straight urinary catheter for a male patient should...
A. grasp the penis at its base
B. apply light traction to the penis
C. hold the penis parallel to the patient's body
D. life the penis to a 45º angle to the patient's body - Answer B. apply light traction to the
penis
Which of the following actions should a nurse take when removing a patient's indwelling
urinary catheter?
A. pull the catheter out as quickly as possible
B. deflate the balloon completely before removal
C. make sure the patient has voided within 12 hr post removal
D. tell the patient to expect to feel a tugging sensation on removal - Answer B. deflate
the balloon completely before removal
A nurse who is administering a return-flow enema to a patient should instill 100 mL of
enema fluid and then....
A. instruct the patient to retain the fluid
B. lower the container to allow the solution to flow back out
C. help the patient to the toilet or beside commode
D. wait 5 min and instill another 100 mL of fluid - Answer B. lower the container to allow
the solution to flow back out
A nurse is administering an enema medication with sodium polystyrene sulfonate
(Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert
the tip of the rectal tube...
A. 2.5-3.75 cm (1-1.5 in)
B. 5-7.5 cm (2-3 in)
C. 7.5-10 cm (3-4 in)
D. 10-12.5 cm (4-5 in) - Answer C. 7.5-10 cm (3-4 in)
A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal
incontinence due to poor sphincter control and is unlikely to retain the enema solution.
Which of the following interventions is appropriate for this patient?
A. Place the patient in the dorsal recumbent position on a bedpan
B. Administer the enema while the patient sits on the toilet
C. Administer an antidiarrheal mediation 3hr prior to the enema
D. Instill 200mL of fluid at 15-minu intervals times four - Answer A. Place the patient in
the dorsal recumbent position on a bedpan
A nurse is preparing to administer an oil-retention enema to a patient who has
constipation. The nurse explains that the patient should try to retain the instilled oil for
A. as long as it takes to complete the procedure
B. about 10-15 minutes
C. until the next time he feels the urge to defecate
D. at least 30 min, but preferably as long as he can - Answer D. at least 30 min, but
preferably as long as he can
,While a nurse is administering a cleansing enema, the patient reports abdominal
cramping. Which of the following is the appropriate intervention?
A. measure the patient's vital signs
B. notify the PCP
C. lower the enema fluid container
D. stop the enema instillation - Answer C. lower the enema fluid container
A patient who is Post Op is experiencing abdominal distention and is having difficulty
expelling flatus. The nurse should anticipate receiving and order from the provider for
which of the following types of enemas?
A. Cleansing
B. Return-flow
C. Medicated
D. Oil-retention - Answer B. Return-flow
A nurse is preparing to administer the first of two large-volume, cleansing enemas
prescribed for a patient in preparation for a diagnostic procedure. Which of the
following is an appropriate step in the procedure?
A. warm the enema solution prior to instillation
B. prepare 1500 mL of enema fluid
C. use tap water as the enema fluid
D. hang the enema container 24 inches above the anus - Answer A. warm the enema
solution prior to instillation
A nurse is preparing an older adult patient for an enema. The nurse should assist the
patient to which of the following positions?
A. prone
B. dorsal recumbent
C. right lateral with both knees at chest
D. left lateral with the right leg flexed - Answer D. left lateral with the right leg flexed
A nurse is applying a condom catheter for an older adult patient who is uncircumcised.
Which of the following is an appropriate step in this procedure?
A. stretching the catheter along the length of the penis
, B. Securing the catheter with adhesive tape
C. Leaving a space between the penis and catheter's tip
D. repositioning the foreskin after application - Answer C. Leaving a space between the
penis and catheter's tip
A nurse is likely to receive an order for urinary catheterization of a newly admitted
patient who...
A. has a persistent UTI
B. has urge incontinence
C. is in the ICU for a GI bleed
D. is incontinent due to cognitive decline - Answer C. is in the ICU for a GI bleed
When providing perineal care for a female patient who has an indwelling urinary
catheter, which of the following areas should the nurse cleanse last?
A. the urethral meatus
B. the labia minora
C. the perineum
D. the anus - Answer D. the anus
A nurse who is preparing to insert a straight urinary catheter for a male patient should...
A. grasp the penis at its base
B. apply light traction to the penis
C. hold the penis parallel to the patient's body
D. life the penis to a 45º angle to the patient's body - Answer B. apply light traction to the
penis
Which of the following actions should a nurse take when removing a patient's indwelling
urinary catheter?
A. pull the catheter out as quickly as possible
B. deflate the balloon completely before removal
C. make sure the patient has voided within 12 hr post removal
D. tell the patient to expect to feel a tugging sensation on removal - Answer B. deflate
the balloon completely before removal
