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57 Cards in this Set
- Front
- Back
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enema is a solution introduced into the __ & __
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rectum & sigmoid colon
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a cleansing enema stimulates __ by irritating the colon & rectum
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peristalsis
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a tap enema, which is a type of a __ enema, is given mostly before __ studies to clean as much of the colon as possible. The amount is usually 1000 ml
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cleansing - diagnostic
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the __ cleansing enema is given to clean the rectum & the sigmoid. The usual amount of solution used is __ mL
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low - 1000
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a carminative enema is given primarily to expel __
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gas
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a oil retention enema, given to __ feces, introduces __ into the rectum & sigmoid colon, & is held inside from one to several __
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soften - oil - hours
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Harris flush or __ __ enema is used to expel __. Alternative flow of __ mL of fluid into & out of the large intestines stimulates peristalsis & the expulsion of flatus
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return flow - flatus - 100-200
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the rectum of an average adult is empty until __ (__ inches in length)
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defecation - 6-8
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if the resistance is encountered at the internal sphincter ask the pt to __ __ __
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breath out slowly
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the solution container should be raised above the __ of the client no higher than __ inches
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rectum - 12 - 18
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sitz bath it is a bath in which only the __ & __ areas are immersed in __ fluid
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perineal & rectal - warm
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sitz bath procedure is used after __ (episiotomy), after __ or __ surgery to reduce swelling, inflammation, & pain
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childbirth - rectal or perineal
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5 causes of fecal impaction
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poor bowel habits - inactivity - dehydration - improper diet - drugs causing constipation - incomplete cleansing after barium studies
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5 contraindications to digital removal of fecal impaction
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pregnancy - hemorrhoids, polyps - HX of MI, CHF, pulmonary emboli - post-op urinary, abdominal, perineal or gynecological surgery - elevated intraocular pressure (glaucoma), increased intracranial pressure
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complication from digital removal of fecal impaction
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mucosal bleeding
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valsalva maneuver is __ (voluntary/involuntary) contraction of abdominal muscles during forced__.
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involuntary - expiration
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fecal impaction can be used to help expel __.
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feces
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fecal impaction May cause changes in __& __
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heart rate & rhythm
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fecal impaction is contraindicated in patients with history of __ problems
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heart
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prevent N/V & gastric distention post surgery
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salem sump - levin - miller-abbott
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provide a route for feeding
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dobhoff - levin
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remove stomach contents for lab analysis
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levin - salem sump
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allow gastric lavage in case poisoning or drug OD
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levin - salem sump
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before administering the feedings or medications through the tube: assess for feelings of … (3)
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abdominal distention, bowel tones, allergies
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before administering the feedings or medications through the tube: position client to __ position
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semi fowler
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before administering the feedings or medications through the tube: confirm tube placement by injecting __ mL bolus of __ using a 60cc syringe & auscultating over the __
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30 - air - stomach
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before administering the feedings or medications through the tube: aspirate __ __ contents, measure the amount & check about __ it or __. (checking pH is most accurate)
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gastric stomach - reinstilling - discarding
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most accurate in administering the feedings or medications is __
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aspirate
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after administering the feedings or medications through the tube: flush the __ with water
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tube
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after administering the feedings or medications through the tube: __ the tube before all the water has run through
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clamp
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after administering the feedings or medications through the tube: have the client remain in a __ __ position for at least __ minutes
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semi-fowlers - 30
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NGT - naso-gastric tube examples (4)
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levin tube - salem sump - dobhoff - core pack
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PEG (__)
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percutaneous endoscopic gastrostomy
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Gastronomy - surgical creation of a __ through the __ wall
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fistula - abdominal
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Jejunostomy - surgical creation of an opening into the __
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jejunum
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signs of tube feeding intolerance: (4)
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nausea, cramping, vomiting, diarrhea
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infiltration is the escape of iv fluid into the __ __. It occurs when the catheter has become dislodged from the __ & allowing the iv fluid to flow into the __ tissues
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interstitial tissue - vein - subcutaneous
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4 clinical signs of infiltration
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swelling - cooling - pain or discomfort - pallor at site
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inflammation of the vein is __
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phlebitis
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an adult has normally __ liters of blood in circulation
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5-six
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when an IV is administered rapidly, __ can occur
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circulation overload
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4 S/S of pulmonary edema from circulatory overload are
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coughing frothy sputum - dyspnea - weak, rapid pulse - rales/crackles
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5 efficient & proficient nurses must check the following in patients with iv therapy
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correct solution-bag dated - correct rate-tubing dated - check for signs of infiltration - i/o - check tubing for kinks/blockage - taped securely-site dated
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6 different oxygen delivery systems & specify whether it is a low flow or high flow system
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nasal cannula - simple mask - venturi mask - partial rebreather mask - non-rebreather mask - aerosols
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which O2 delivery system - low flow 2-6L/min
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Nasal cannula
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which O2 delivery system - low flow 6-8 L/min or 35-60%
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Simple mask
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which O2 delivery system - high flow - exact o2 concentration
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Venturi mask
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which O2 delivery system - low flow - 6-10 L 65-75% o2
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Partial rebreather mask
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which O2 delivery system - low-flow - 8-12 L 85-90% o2
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Non rebreather mask
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which O2 delivery system - 8-10 L/min
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Aerosols
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which O2 delivery system - easily tolerated
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nasal cannula (prongs)
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which O2 delivery system - at least 5 L/min
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Simple mask
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which O2 delivery system - exact o2 concentration
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venturi mask
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which O2 delivery system - high humidity
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aerosols
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which O2 delivery system - mixes air & O2
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partial rebreather mask
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which O2 delivery system - one way valve - 60-90%
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nonrebreather mask
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enumerate & explain at lease 3 safety precautions with o2 therapy
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No smoking - Ensure that all electrical equipment is functioning well - Know facility's fire safety procedure & location of closes fire extinguisher
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