NUR 235 Exam 2
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1. A nurse is preparing to administer an d) at least 30 min
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?
a) the duration of the procedure
b) 10 to 15 min
c) until the client feels the urge to defe-
cate
d) at least 30 min
2. a nurse is prepapring an adult client for d) left lateral with the right leg flexed
an enema. the nurse should assist the
client into which of the following posi- (makes it easier for enema solution to flow by
tion? gravity into the sigmoid and descending colon,
flexed leg promotes exposure of anus for rectal
a) prone tube insertion)
b) dorsal recumbent
c) right lateral with both knees at chest
d) left lateral with the right leg flexed
3. a client who is postoperative is experi- b) return flow
encing abdominal distention and is hav-
ing difficult expelling flatus. the nurse expel flatus, stimulate peristalsis, and relieve
should expect the provider to prescribe abdominal distention
which of the following types of enemas?
a) cleaning
b) return flow
c) medicated
d) oil-retention
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
4. a nurse is preparing to administer a a) place the client in the dorsal recumbent po-
cleansing enema to a client who has sition on a bedpan
poor sphincter control. which of the fol-
lowing actions should the nurse take?
a) place the client in the dorsal recum-
bent position on a bedpan
b) administer the enema while the client
sits on the toilet
c) administer an antidiarrheal medica-
tion 3 hr prior to the enema
d) instill 200 mL of fluid over an hour at
15-min intervals
5. a nurse is administering an enema c) 7.5 cm to 10 com (3-4 in)
medicated with sodium polystyrene sul-
fonate to an adult client who has hy-
perkalemia. to which of the following
lengths should the nurse insert the rec-
tal tube?
a) 2.5 cm to 3.75 cm (1 to 1.5 in)
b) 5 cm to 7.5 cm (2-3 in)
c) 7.5 cm to 10 com (3-4 in)
d) 10 cm to 12.5 cm (4-5 in)
6. when a nurse is administering a cleans- c) lower the enema fluid container
ing enema, the client reports abdomi-
nal cramping. which of the following ac-
tions should the nurse take?
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
a) measure the clients vital signs
b) notify the primary care provider
c) lower the enema fluid container
d) stop the enema instillation
7. a nurse is administering a return-flow b) lower the container to allow the solution to
to a client. after instilling 100mL of ene- flow back out
ma fluid, which of the following actions
should the nurse take? (return flow enemas involve moving 100-200
mL in and out of rectum. after instilling the
a) instruct the cleint to retain the fluid solution, the nurse lowers the container to allow
b) lower the container to allow the solu- the solution to flow back in and out)
tion to flow back out
c) help the client to the toilet or bedside
commode
d) wait 5 min and instill another 100 mL
of fluid
8. a nurse is preparing to administer the a) warm the enema solution prior to instillation
first of two large-volume, cleansing en-
emas prescribed for a client in prepara- (cold fluid can cause cramping, too hot can
tion for a diagnostic procedure. which injure intestinal membrane)
of the following action should the nurse
take?
a) warm the enema solution prior to in-
stillation
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
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
9. which of the following actions should a a) auscultate the client's lungs
nurse take to assess a client who had
a stroke for complications secondary to silent aspirations are common complications of
inadequate swallow? swallowing impairment
a) auscultate the client's lungs
b) place the tip of a tongue depressor on
the client's posterior tongue
c) inspect the client's uvula and soft
palate with a penlight
d) place fingers on the clients throat at
the level of the larynx and ask the client
to swallow
10. a nurse is reviewing a client's lab val- a) albumin level is a poor short term indicator
ues. which of the following information of protein status
is correct regarding albumin levels and
nutritional status?
a) albumin level is a poor short term
indicator of protein status
b) hydration status does not affect a
client's albumin level
c) an albumin level of 3.2 d/dL is within
the expected reference range
d) albumin level is calculated by keeping
a 24-hr record of protein intake
11. what is the excretion of waste products; elimination
passage of stool through the intestinal
tract or urine through the urinary tract?
12. positive consequences of elimination?
Study online at https://quizlet.com/_fivuw0
1. A nurse is preparing to administer an d) at least 30 min
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?
a) the duration of the procedure
b) 10 to 15 min
c) until the client feels the urge to defe-
cate
d) at least 30 min
2. a nurse is prepapring an adult client for d) left lateral with the right leg flexed
an enema. the nurse should assist the
client into which of the following posi- (makes it easier for enema solution to flow by
tion? gravity into the sigmoid and descending colon,
flexed leg promotes exposure of anus for rectal
a) prone tube insertion)
b) dorsal recumbent
c) right lateral with both knees at chest
d) left lateral with the right leg flexed
3. a client who is postoperative is experi- b) return flow
encing abdominal distention and is hav-
ing difficult expelling flatus. the nurse expel flatus, stimulate peristalsis, and relieve
should expect the provider to prescribe abdominal distention
which of the following types of enemas?
a) cleaning
b) return flow
c) medicated
d) oil-retention
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
4. a nurse is preparing to administer a a) place the client in the dorsal recumbent po-
cleansing enema to a client who has sition on a bedpan
poor sphincter control. which of the fol-
lowing actions should the nurse take?
a) place the client in the dorsal recum-
bent position on a bedpan
b) administer the enema while the client
sits on the toilet
c) administer an antidiarrheal medica-
tion 3 hr prior to the enema
d) instill 200 mL of fluid over an hour at
15-min intervals
5. a nurse is administering an enema c) 7.5 cm to 10 com (3-4 in)
medicated with sodium polystyrene sul-
fonate to an adult client who has hy-
perkalemia. to which of the following
lengths should the nurse insert the rec-
tal tube?
a) 2.5 cm to 3.75 cm (1 to 1.5 in)
b) 5 cm to 7.5 cm (2-3 in)
c) 7.5 cm to 10 com (3-4 in)
d) 10 cm to 12.5 cm (4-5 in)
6. when a nurse is administering a cleans- c) lower the enema fluid container
ing enema, the client reports abdomi-
nal cramping. which of the following ac-
tions should the nurse take?
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
a) measure the clients vital signs
b) notify the primary care provider
c) lower the enema fluid container
d) stop the enema instillation
7. a nurse is administering a return-flow b) lower the container to allow the solution to
to a client. after instilling 100mL of ene- flow back out
ma fluid, which of the following actions
should the nurse take? (return flow enemas involve moving 100-200
mL in and out of rectum. after instilling the
a) instruct the cleint to retain the fluid solution, the nurse lowers the container to allow
b) lower the container to allow the solu- the solution to flow back in and out)
tion to flow back out
c) help the client to the toilet or bedside
commode
d) wait 5 min and instill another 100 mL
of fluid
8. a nurse is preparing to administer the a) warm the enema solution prior to instillation
first of two large-volume, cleansing en-
emas prescribed for a client in prepara- (cold fluid can cause cramping, too hot can
tion for a diagnostic procedure. which injure intestinal membrane)
of the following action should the nurse
take?
a) warm the enema solution prior to in-
stillation
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
, NUR 235 Exam 2
Study online at https://quizlet.com/_fivuw0
9. which of the following actions should a a) auscultate the client's lungs
nurse take to assess a client who had
a stroke for complications secondary to silent aspirations are common complications of
inadequate swallow? swallowing impairment
a) auscultate the client's lungs
b) place the tip of a tongue depressor on
the client's posterior tongue
c) inspect the client's uvula and soft
palate with a penlight
d) place fingers on the clients throat at
the level of the larynx and ask the client
to swallow
10. a nurse is reviewing a client's lab val- a) albumin level is a poor short term indicator
ues. which of the following information of protein status
is correct regarding albumin levels and
nutritional status?
a) albumin level is a poor short term
indicator of protein status
b) hydration status does not affect a
client's albumin level
c) an albumin level of 3.2 d/dL is within
the expected reference range
d) albumin level is calculated by keeping
a 24-hr record of protein intake
11. what is the excretion of waste products; elimination
passage of stool through the intestinal
tract or urine through the urinary tract?
12. positive consequences of elimination?
