Midterm Review Flashcards
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. Which of the following is the probable cause of these symptoms and findings?
Cystitis is usually marked by urinary frequency and irritation. The cloudiness is usually indicative of bacterial presence.
Hospital-acquired urinary tract infections (UTIs) are most often related to poor hand hygiene and which of the following?
urinary catheterization has the highest potential for causing UTIs, and improper catheter care can increase the chance of these infections
To minimize nocturia, when should patients avoid fluids?
avoid fluids for 2 hours before bedtime.
A Foley catheter drainage bag is placed below the bladder to prevent which of the following?
prevent urinary reflux, which can lead to infection
When a condom catheter is applied, the catheter should be secured on the penile shaft in such a manner that the catheter is which of the following?
should fit snugly and securely but should not cause constriction that impedes blood flow. It should not be tight or placed in a dependent position and should never be secured with tape in a circular pattern, which could impede blood flow.
A patient undergoes ultrasonography of a kidney. The nurse providing postprocedure care remembers that which of the following is true regarding precautions that should be taken for this procedure?
no special precautions are necessary after ultrasonography
A patient underwent total knee replacement and was placed on patient-controlled analgesia. The patient has been activating the medication button an average of four times per hour. The nurse has assisted the patient on and off the bedpan two or three times an hour for the past 2 hours. Urine output was about 50 mL with each void. The nurse now begins to suspect which of the following?
retention overflow. Urinary retention may cause increased pressure in the bladder to the point that the external urethral sphincter is unable to hold back urine. The sphincter temporarily opens to allow a small volume of urine to escape. Bladder pressure then falls, and the sphincter closes again. The nurse should also assess the lower abdomen for bladder distension
the nurse recognizes that which organism most frequently causes UTIs in women?
Because the female urethra is positioned close to the anus, most UTIs are a result of contamination of the urethra with organisms from the gastrointestinal tract, such as E. coli.
A 34-year-old man is in hospital rehabilitating from a spinal cord injury. He is incontinent of urine at regular intervals. He is unaware when he is incontinent. This describes which of the following types of incontinence?
Reflex incontinence is the involuntary loss of urine at regular intervals. The person is unaware that the bladder is filling and does not feel the urge to void.
Stress incontinence
Stress incontinence occurs with activities that increase intra-abdominal pressure, such as coughing and sneezing.
transient incontinence
Transient incontinence is a temporary incontinence that resolves once its underlying causes are treated, such as dementia or infection.
Urge incontinence
Urge incontinence is associated with a sudden, urgent need to void and often presents with urinary frequency and nocturia. Its causes include nervous system disorders and outflow obstruction.
Urine may appear concentrated and cloudy because of the presence of
white blood cells or bacteria.
An obstruction to the flow of urine in the urinary collecting system may cause which of the following?
renal damage, urinary retention and UTI
Shear
Force exerted parallel to the skin and results from both gravity pushing down on the body and resistance (friction) between the patient and a surface.
Friction
The force of two surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens
The braden scale is compromised of what six categories
sensory perception, moisture, activity, mobility, nutrition and friction &shear.
The lower the score the higher the risk of a pressure injury development, total scores range from 6-23.
Granulation
red, moist tissue composed of new blood vessels which indicated progression of wound healing
slough
soft yellow or white stringy tissue which needs to be removed before wound will heal (dead tissue)
eschar
black or brown necrotic tissue which needs to be removed before wound will heal (dead tissue)
acute wounds
Abrasion is superficial wound with little bleeding
Laceration is a jagged unintentional wound that sometimes bleeds more profusely
Surgical wounds
a cut or incision that was intentionally made by a scalpel; can also be the result of a drain placed during surgery
Primary intention
skin edges are approximated with sutures, staples or tape
low infection risk
quick healing with minimal scar
surgery wound heals by this time
secondary intention
wound is large and irregular with considerable tissue loss
edges are not approximated
longer healing time with pronounced scarring
higher infection risk
tertiary intention
wound left open due to possible contamination - require observation
edges approximated once wound is clean
Inflammatory phase (wound healing)
Beginning within minutes of the injury and lasting up to three days depending on thickness of wound.
Body process - hemostasis, phagocytosis
Appearance - mild redness, swelling
Proliferative Phase (wound healing)
New blood vessels appear as reconstruction progresses, lasts from 3 to 24 days
Body process - collagen strengthens wound, produces scar tissue. Granulation tissue is highly vascular
Appearance - wound bed whitish then translucent, red/friable. Raised healing ridge on sutured wound
