Perfusion, Gas Exchange, And Elimination Flashcards
What is the proper procedure when cleaning the female perineal area with iodine?
First make sure the client is not allergic to betadine or iodine, then always clean from the meats downward (front to back)
A nurse is beginning a foley catheter insertion on a client with urinary retention. Which hand is sterile and what should it hold?
Dominant hand, the tip of the Foley catheter with the rest coiled in the hand
Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?
Checking the documentation for the volume of fluid used to inflate the balloon
A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take with action?
Notify the PHCP before performing the catheterization
The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
Clamp the tubing for 30 minutes and then release
Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications.
Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient’s comfort when a condom catheter is applied?
Use a hair guard before applying the condom catheter.
To ensure the patient’s comfort, the nurse would instruct NAP to use a hair guard before applying the condom catheter, and will prevent hair pulling leading to skin irritation.
A 36-year-old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen?
“First, I will pee a small amount of urine in the toilet and then collect the rest in the cup.”
What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?
Make a note on the lab slip that the patient is menstruating.
Case Study: Abdominal Pain:
J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the ‘sides of my back.’ J.M. is also nauseated.
J.M. is appears restless and keeps moving from back to side to reduce her discomfort.
Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness.
J.M. is voiding small amounts of orange-red urine.
What are the possible causes of J.M.’s abdominal pain, nausea, and urine color?
Urinary tract infection
Renal Calculi
Pyelonephritis
J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the ‘sides of my back.’ J.M. is also nauseated.
J.M. is appears restless and keeps moving from back to side to reduce her discomfort.
Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness.
J.M. is voiding small amounts of orange-red urine.
What assessment questions would be most appropriate for J.M. ?
“Has there been a change in the color of urine such as bloody or cloudy?”
“Has there been a change in characteristics of urination, such as diminished or excessive?
“Is it painful when you urinate?”
J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the ‘sides of my back.’ J.M. is also nauseated.
J.M. is appears restless and keeps moving from back to side to reduce her discomfort.
Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness.
J.M. is voiding small amounts of orange-red urine.
Which physical assessment findings are of most concern to you as you perform a ‘focused’ assessment?
Assess abdominal pain
Assess Flank Pain
Assess vital signs
Based on the results of the subjective and physical assessment findings, what lab studies do you think may be ordered for J.M.?
CBC
Urinalysis
Urine culture (“clean catch”)
J. M’s urinalysis shows severe hematuria, and her CBC reveals an elevated WBC count. The HCP has diagnosed J.M. as having Pyelonephritis. The HCP prescribes Ciprofloxacin 500 mg tid for 7 days. J.M. asks the RN how can she avoid getting a UTI so that she does not have this problem again?
Upon discharge, what will you include in the teaching plan?
When you have a bowel movement, wipe from front to back
Be sure and urinate, before and after sexual intercourse
Drink 8-10 glasses of water per day
When preparing to perform a 12-lead electrocardiogram on a client, which action(s) should the nurse take?
Prepare the skin before attaching electrodes
Explain steps for relaxation and breathing
Verify the client using two identifiers
Visualizes the chest and extremities
The nurse recognizes that the goal for placement of lead V6 has been met when the lead is placed in a straight line with V4 and V5 and coinciding underneath which location?
The left axilla
Interpret the following ABG:
pH- 7.27
pCO2- 34
HCO3- 15
PaO2- 90
Metabolic Acidosis
Interpret the following ABG:
pH- 7.33
PCO2- 50
HCO3- 28
PaO2- 87
Respiratory Acidosis
