BSN206 EXAM: 2025/2026 WITH
CORRECT/ACCURATE ANSWERS
An increase in venous pressure caused by liver disease can result
in the development of:
Hemorrhoids.
Flatulence.
Impaction.
Diarrhea. - CORRECT ANSWERS- Hemorrhoids
Which of the following vital signs recorded for an older adult
would be considered acceptable (within normal limits)?
Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%.
Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%.
Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88% -
CORRECT ANSWERS- Temp 97.0° F (36.1 °C), P-60, R-16, BP
116/78, O2 sat 95%.
The comatose patient in the intensive care unit (ICU), who has not
had a bowel movement in 4 days, suddenly is incontinent of liquid
stool. What should the nurse suspect?
Diarrhea as a result of decreased muscle tone.
,Impaction.
The patient had a vagal response.
Flatulence. - CORRECT ANSWERS- Impaction
The nurse is monitoring the patient for a possible vagal response
while removing a fecal impaction. If the patient had a vagal
response, what would the nurse most likely observe?
Tachycardia.
Hypertension.
A decrease in heart rate.
A decrease in respirations. - CORRECT ANSWERS- A decrease in
heart rate
An adult patient is scheduled for an abdominal computed
tomography (CT) scan. Before the scan he must receive a
cleansing tap water enema. The nurse should prepare:
At least 2000 mL of tap water.
Correct! 1000 mL or less of tap water.
5 mL of castile soap and 1500 mL of water.
180 mL of prepackaged (Fleet) enema solution. - CORRECT
ANSWERS- 1000 mL or less of tap water
The health care provider has ordered a Fleet enema for a patient
experiencing constipation. Which of the following actions would
require correction?
,The nurse delegates the task to nursing assistive personnel (NAP).
The nurse removes the protective cap from the rectal tip.
The nurse squeezes and releases the bottle several times until all
of the solution has entered the patient.
The nurse administers the enema at room temperature, or if too
cool, warms the solution by holding the bottle under warm
running water. - CORRECT ANSWERS- The nurse squeezes and
releases the bottle several times until all of the solution has
entered the patient
An adult patient complains of cramping during the administration
of an enema. What could be a possible cause? (Select all that
apply.)
The solution was instilled too rapidly.
The patient was placed in Sims' position.
The enema bag was held too low during the infusion.
The enema solution was too cold.
The lubricated rectal tip was inserted 3 to 4 inches. - CORRECT
ANSWERS- The solution was instilled too rapidly
The enema solution was too cold
Which of the following is the best example of documentation of
enema administration?
0800 1000 mL tap water enema administered without difficulty.
Moderate return of soft formed brown stool.
1000 Soap suds enema administered. Patient tolerated well.
, 0830 800 mL tap water enema administered. Return clear with no
fecal material Bowel sounds present in all 4 quadrants pre and
post procedure. Abdomen nondistended. Patient states "I'm glad
that's over."
0900 1000 mL warmed tap water with 5 mL castile soap enema
administered per health care provider's order. Patient instructed
not to flush toilet. Patient held enema solution approximately 5
minutes. Good return. Patient repositioned for comfort. Call light
in reach. - CORRECT ANSWERS- 0830 800 mL tap water enema
administered. Return clear with no fecal material Bowel sounds
present in all 4 quadrants and post procedure. Abdomen
nondistended. Patient stated "I'm, glad that's over"
The nurse is observing the NAP administer a soap suds enema to
an adult patient. Which of the following actions, if made by the
NAP, would require correction?
The NAP holds the enema container approximately 12 inches
above the level of the patient's anus.
The NAP places the patient in a left side-lying position with the
right knee flexed.
The NAP inserts the tip of the rectal tube 5 to 7 inches after
lubricating it.
After filling the enema bag with warmed solution, the NAP raises
the container, releases the clamp, and allows the solution to flow
to fill the tubing. - CORRECT ANSWERS- The NAP inserts the tip of
the rectal tube 5 to 7 inches after lubricating it
CORRECT/ACCURATE ANSWERS
An increase in venous pressure caused by liver disease can result
in the development of:
Hemorrhoids.
Flatulence.
Impaction.
Diarrhea. - CORRECT ANSWERS- Hemorrhoids
Which of the following vital signs recorded for an older adult
would be considered acceptable (within normal limits)?
Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%.
Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%.
Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88% -
CORRECT ANSWERS- Temp 97.0° F (36.1 °C), P-60, R-16, BP
116/78, O2 sat 95%.
The comatose patient in the intensive care unit (ICU), who has not
had a bowel movement in 4 days, suddenly is incontinent of liquid
stool. What should the nurse suspect?
Diarrhea as a result of decreased muscle tone.
,Impaction.
The patient had a vagal response.
Flatulence. - CORRECT ANSWERS- Impaction
The nurse is monitoring the patient for a possible vagal response
while removing a fecal impaction. If the patient had a vagal
response, what would the nurse most likely observe?
Tachycardia.
Hypertension.
A decrease in heart rate.
A decrease in respirations. - CORRECT ANSWERS- A decrease in
heart rate
An adult patient is scheduled for an abdominal computed
tomography (CT) scan. Before the scan he must receive a
cleansing tap water enema. The nurse should prepare:
At least 2000 mL of tap water.
Correct! 1000 mL or less of tap water.
5 mL of castile soap and 1500 mL of water.
180 mL of prepackaged (Fleet) enema solution. - CORRECT
ANSWERS- 1000 mL or less of tap water
The health care provider has ordered a Fleet enema for a patient
experiencing constipation. Which of the following actions would
require correction?
,The nurse delegates the task to nursing assistive personnel (NAP).
The nurse removes the protective cap from the rectal tip.
The nurse squeezes and releases the bottle several times until all
of the solution has entered the patient.
The nurse administers the enema at room temperature, or if too
cool, warms the solution by holding the bottle under warm
running water. - CORRECT ANSWERS- The nurse squeezes and
releases the bottle several times until all of the solution has
entered the patient
An adult patient complains of cramping during the administration
of an enema. What could be a possible cause? (Select all that
apply.)
The solution was instilled too rapidly.
The patient was placed in Sims' position.
The enema bag was held too low during the infusion.
The enema solution was too cold.
The lubricated rectal tip was inserted 3 to 4 inches. - CORRECT
ANSWERS- The solution was instilled too rapidly
The enema solution was too cold
Which of the following is the best example of documentation of
enema administration?
0800 1000 mL tap water enema administered without difficulty.
Moderate return of soft formed brown stool.
1000 Soap suds enema administered. Patient tolerated well.
, 0830 800 mL tap water enema administered. Return clear with no
fecal material Bowel sounds present in all 4 quadrants pre and
post procedure. Abdomen nondistended. Patient states "I'm glad
that's over."
0900 1000 mL warmed tap water with 5 mL castile soap enema
administered per health care provider's order. Patient instructed
not to flush toilet. Patient held enema solution approximately 5
minutes. Good return. Patient repositioned for comfort. Call light
in reach. - CORRECT ANSWERS- 0830 800 mL tap water enema
administered. Return clear with no fecal material Bowel sounds
present in all 4 quadrants and post procedure. Abdomen
nondistended. Patient stated "I'm, glad that's over"
The nurse is observing the NAP administer a soap suds enema to
an adult patient. Which of the following actions, if made by the
NAP, would require correction?
The NAP holds the enema container approximately 12 inches
above the level of the patient's anus.
The NAP places the patient in a left side-lying position with the
right knee flexed.
The NAP inserts the tip of the rectal tube 5 to 7 inches after
lubricating it.
After filling the enema bag with warmed solution, the NAP raises
the container, releases the clamp, and allows the solution to flow
to fill the tubing. - CORRECT ANSWERS- The NAP inserts the tip of
the rectal tube 5 to 7 inches after lubricating it
