1 REVIEWER: NCM 109 Laboratory
i. Student nurse EJ observe his clinical instructor hardened feces and lodgment of something
doing a demonstration in cleaning the penis such as feces in a body passage or cavity
from the meatus to the base before performing o False
the catheterization, his clinical instructor is o True
correct if performs it using? ix. What part of the patient’s body you are going to
o Circular motion drape as part of your nursing responsibility in
o One upward stroke performing catheterization?
o None of the choices o Px thigh to mid-legs
o Any motion o Px legs to mid-thigh
ii. An enema can be used to treat ____? o Px legs to mid-buttocks
o Vomiting o Px legs to mid-knee
o Acid reflux x. Care for an indwelling urinary catheter should
o Diarrhea include which of the following interventions?
o Constipation o Remove obvious encrustations from the
iii. Risk of catheterization include all except? external catheter surface by washing it
o Trauma to urethral meatus gently with soap water
o All of the choices o Insert the catheter using clean
o Spasm and gall bladder pain technique
o Urinary tract infection o Lay the drainage bag on the floor to
iv. Nurse EJ tape the catheter tube to the inner allow for maximum drainage through
thigh, he is doing the right step also if he gravity
hooked the drainage bag where? o Keep the drainage bag on the bed with
o On the bed the client
o On the bedframe xi. What is the best position of the client before
o On the bedpan performing enema?
o On the floor o Right lateral position
v. Haw far you go in inserting the catheter to the o Left lateral position
urethra? o Right vertical position
o All of the choices o Left vertical position
o 6-8 cm xii. What is the ideal temperature of the enema
o 6-8 feet solution to prevent patient feeling
o 6-8 inches uncomfortable and cause muscle cramping?
vi. These are the common enema used in adults o 47.7 degrees Fahrenheit
except o 37.7 degrees Fahrenheit
o Soap water o 37.7 degrees Celsius
o Olive oil o 47.7 degrees Celsius
o Chloroform water xiii. One of the purposes of administering enema is
o saline to prevent the escape of feces during surgery?
vii. what should the nurse do to ensure good o True
visualization of the anus aside from the left o false
lateral position of the client? xiv. EJ your clinical instructor during your online
o Lift the lower extremities class, define several terms, he mentioned that
o Lift the upper buttock enema is?
o Lift the lower buttock o The solution introduced into the mouth
o None of the choices and down large intestine
viii. Another purpose of administering enema is to o The solution introduced into the rectum
remove feces in instances of abnormally and large intestine
delayed or infrequent passage of usually dirt
2 REVIEWER: NCM 109 Laboratory
o The solution introduced into the rectum o Blanket
and stomach o Abdominal drape
o The solution introduced into the rectum xxii. Nurse EJ perform catheterization to his patient,
and small intestine before reapplying the external catheter, what is
xv. The main purpose of enema is to __ in the best nursing intervention he should do?
constipation or before an operation? o Hand hygiene
o Expel flatus o Check doctor’s order
o Soften the feces o Flushing only
o Evacuate the feces o Perineal care
o Lubricate the feces xxiii. In relation to changing external catheter, nurse
xvi. What is your student nurse responsibility if the EJ listen to the orientation regarding facilities
drainage system is accidentally disconnected? protocol in changing external catheter, he is
o None of the choices correct if he remembered?
o Tell the significant others o On a doctor’s order
o Tell the nurse at once o On a case-to-case basis
o Tell the nurse at the end of the shift o On a daily basis
xvii. These are the main risk of enema except? o On a weekly basis
o Irritation to vaginal mucosa xxiv. Student nurse EJ performed catheterization, he
o Water intoxication understood the procedure if he taped the
o Osmosis of enema solution catheter to prevent from pulling to what
o Electrolyte imbalance patient’s body part except?
xviii. As a nurse, our nursing responsibility is to o None of the choices
explain the action of enema to the patient, you o Px limb
are correct if you explain that enema action is? o Px upper extremities
o It irritates the intestinal mucosa only o Px leg
o It distends the intestine and irritate the xxv. A carminative enema is given to a patient to?
intestinal mucosa o Evacuate the feces
o It does not distend the intestine and o Lubricate the feces
irritate the intestinal mucosa o Soften the feces
o It distends the intestine only o Expel flatus
xix. What is the best nursing interventions or xxvi. After placing the fenestrated drape, with your
responsibility while inserting the catheter there non-dominant hand, what is the appropriate
is resistance upon entry? angle in holding the px penis?
o Allow bladder to empty o 90 degrees angle
o All of the above
o Rotate the catheter slightly another
inch
o Ask px to breathe deeply
xx. The force flow of enema can be controlled by? xxvii. Which of the following is correct about
o Pathologic injury physiological response to heat?
o Size of the tube o It decreases supply of nutrients
o Type of tube o The muscle contracts
o Body temperature o It decreases peristalsis
xxi. _______ area. He is to perform catheterization, o Causes vasodilation thus increases
Nurse EJ is correct if he use this drape to cover blood flow to affected area
patients’ genitalia? xxviii. All statements are correct about patient done
o Bath towel performed hot sitz bath, but what will the last
o Fenestrated drape steps to do in a procedure?
3 REVIEWER: NCM 109 Laboratory
o Assist patient out of tub then dry him o 110 – 120 F
o Cleanse the materials and return to its o 130-140 F
proper place and blood circulation o 85-90 F
o Do documentation o 90-95 F
o Wash tub with soap and running water xxxv. What priority information would be important
xxix. Which statement of Perilite procedures indicate to give to the patient about perineal care?
that the student nurse needs additional o To lessen the pain
teaching? o To prevent infection during delivery
o Provide bed screen/curtains and o It is necessary to perform to all the
arrange beddings to expose only part to patients
which treatment is to be given o To prevent tearing of the perineum
o Explain procedure to the patient xxxvi. Part of a female genitalia that is also known as
o You can just estimate how long the large lips
expose of the perilite o Vestibule
o Review physician order o Labia majora
xxx. It is a procedure that hasten the wound healing o Labia minora
by means of perineal lamp o Mon pubis
o Dry heat xxxvii. Which action by the nurse is the most
o Hot sitz bath appropriate for perineal care?
o Perilite exposure o Nurse prepare the exposure of the
o Heat application female genitalia to provide easy access
xxxi. Which action by the nurse is most appropriate prior the procedure
about doing the hot sitz bath? o Assist patient to dorsal recumbent
o Ask and help patient to sit squarely on position, extend knees and legs
tub o Always wash from dirty to clean area
o The temperature of water is 85-90F o Nurse performed with another patient
o Let the patient wear patient gowns xxxviii. Which statement indicates incorrect regarding
during the procedure the steps of doing perineal care?
o It is not necessary to the patient if he o Cleanse the perineal area using soaked
will not void before the procedure in betadine cleanser
xxxii. A procedure where it is the application of dry o Cleansing should be done from vagina
heat to perineal area to provide comfort and outward
blood circulation o Washing should be from dirtiest to
o Hot sitz bath cleanest part
o Perineal wash o Explain procedure to the patient
o Perilite exposure xxxix. What information would be important to give
o Perineal care the patient about perilite?
xxxiii. All of the following details to include in o It takes time to heal the wounds
documentation after performed the hot sitz o To provide comfort and increase blood
bath except circulation
o Type of treatment o Will not relieve the pain of the affected
o Patient’s identity area
o Type of heat application o It is invasive procedure
o Length of time of application xl. A procedure refers to an incision through the
xxxiv. A patient has a hot sitz bath ordered. They ask perineum that allows for less pressure on the
how gradually the hot should the water be. fetal head during delivery and prevents
What is the most appropriate water lacerations of the perineum
temperature? o Perineorrhaphy
4 REVIEWER: NCM 109 Laboratory
o Heat application o The inner aspects of thighs and arms
o Episiotomy o Skin
o Episiorrphy o Legs
xli. Based on the 8 strokes pattern for cleaning the o forehead
perineal area, on which level of sponge indicate xlviii. The indication only of perineal care is to protect
are used to cleanse the side of the labia with a from contamination before giving birth
downward sweep? o False
o Fourth and fifth sponges o True
o Second sponge xlix. An operation for repairing lacerations of
o Third sponge perineum following delivery.
o Sixth, seventh and eight sponges o Episoprraphy
xlii. Which is not the indication for hot sitz bath? o Perilite
o Uterine cramps o Perineorraphy
o Hemorrhoids o Episiotomy
o Episiotomy l. How many inches away the perilite exposure fro
o headache the perineum to avoid burning the area?
xliii. what is the nurse best response if patient asks o 25-27 inches
about hot sitz bath? o 16-17 inches
o Patient perineal area are submerged o 28-30 inches
water with solution depending on the o 18-24 inches
needs of client li. How far do you ideally lubricate the rectal tube?
o Pour lukewarm water on perineal area o 5 cm
o All patients will undergo hot sitz bath lii. Indicates for foley catheterization include all
o Application of dry heat on a perineal except?
area o Collection of sterile urine sample
xliv. Which concern for patient safety who will o Measuring residual urine volumes
undergo perilite treatment? o In preparation for a night of beer
o Patient took a bath and still wet all over drinking
her body o Urinary retention
o Patient wearing jewelry liii. What is the most important nursing
o Patient’s thirsty responsibility aside from hand hygiene while
o Patient’s hungry performing enema?
xlv. A process of heat application that requires a o Provide for client comfort
higher temperature and a longer period of o Provide for client privacy
heating o Provide for client option
o Heat application liv. What is your first nursing responsibility before
o Perilite exposure administering enema?
o Dry heat o Check for primary care provider’s order
o Moist heat lv. All are correct about the principles involved
xlvi. Which patient condition where hot sitz bath is perilite exposure except:
contraindicated? o Heat causes vasoconstriction
o Patients with episode of migraine lvi. A process of heat application which utilizes hot
o A pregnant woman air that is heavily laden with water vapor
o Patient with cough o Moist heat
o Patient with sore throat lvii. The following are the correct on how hot sitz
xlvii. Individual tolerance to heat depends on the bath works EXCEPT
number of heat receptors in body parts. Which o To prevent infection
part of the body is sensitive to heat?
5 REVIEWER: NCM 109 Laboratory
o To hasten healing area around the
perineum
o It relieves muscle spasm
o Effective treatment to patient like
having hemorrhoids
lviii. What body mechanics of the patient you have
to properly expose of the perilite?
o Side lying position
o Supine position
o Dorsal recumbent with legs and knees
flex
o Squatting position
lix. What do you call a skin-covered pad of fat over
the symphysis pubis?
o Mon pubis
