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Fundamental Test 2 > VN 15 Study Guide 2 > Flashcards

VN 15 Study Guide 2 Flashcards

1
Q

What are the four types of incontinence and describe them

A

• Stress
The loss of small amounts of urine when intra-abdominal pressure rises
• Urge
Need to void perceived frequently with short-live ability to sustain control of the flow
• Total
Loss of urine without any identifiable pattern or warning
• Overflow
Urine leakage because the bladder is not completely emptied; bladder distended with retained urine

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2
Q

The loss of small amounts of urine when intra-abdominal pressure rises

A

Type of incontinence: Stress

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3
Q

Need to void perceived frequently with short-live ability to sustain control of the flow

A

Type of incontinence: Urge

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4
Q

Loss of urine without any identifiable pattern or warning

A

Type of incontinence: Total

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5
Q

Urine leakage because the bladder is not completely emptied; bladder distended with retained urine

A

types of incontinence: Overflow

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6
Q

What is the purpose of a guaiac test?

A

Detects blood in the stool

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7
Q

List nursing interventions for constipation

A

*Increase fiber
*Increase fluids
•Give bulk-forming products before stool softeners, stimulants, or suppositories.
•Enemas are a last resort for stimulating defecation.
*Encourage regular exercise.
*Probiotics

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8
Q

What would the VN instruct the client to avoid prior to taking an at home FOBT?

A
  • nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, ibuprofen, or naproxen, Acetaminophen
  • don’t eat red meat
  • Do not eat raw turnips, radishes, broccoli, beets, carrots, cauliflower, cucumbers, or mushrooms
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9
Q

What are manifestations of a UTI?

A
  • Urinary frequency, urgency, nocturia, flank pain, hematuria
  • dark amber
  • cloudy
  • foul-smelling urine
  • fever.
  • hypotension.
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10
Q

List instructions to collect a 24-hour urine

A
  • Discard the first voiding.
  • Collect all other urine.
  • Refrigerate, label
  • transport the specimen.
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11
Q

difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. Frequency and urgency often accompany

A

Dysuria

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12
Q

(a strong feeling that urine must be eliminated quickly) often accompany dysuria.

A

Urgency

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13
Q

(nighttime urination) is unusual because the rate of urine production is normally reduced at night.

A

Nocturia

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14
Q

urine output less than 400 mL in 24 hours, indicates the inadequate elimination of urine

A

Oliguria

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15
Q

Give an example of a good fluid balance when assessing I&Os

A

30ml/hr

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16
Q

List indications for urinary catheterization

A
  • Assessing fluid balance accurately
  • Keeping the bladder from becoming distended during procedures such as surgery
  • Measuring the residual urine
  • urinary retention or obstruction
  • obvious pereneal wound (opening from the vagina to the anus)
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17
Q

What are diagnostic findings in a UTI?

A
  • Toileting self-care deficit
  • Impaired urinary elimination
  • Urinary retention
  • Risk for infection
  • Stress urinary incontinence
  • Urge urinary incontinence
  • Reflex urinary incontinence
  • Functional urinary incontinence
  • Risk for impaired skin integrity
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18
Q

List client education when teaching about care for an ileal conduit.

A
  • make sure trim of opening 1/16 - 1/8
  • make sure look pink, cherry red, moist
  • change every 3/7 days
  • Change the pouching system once a week
  • Cleaning the stoma and skin with water is enough.
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19
Q

List assessment of an ileostomy. What color should the stoma be? What instructions should be given regarding medications?

A
  • dark pink to red in color and moist.
  • no entercoded medications
  • A pale stoma may indicate anemia
  • dark purple-blue stoma may reflect compromised circulation or ischemia.
  • Bleeding around the stoma and its stem should be minimal..
20
Q

List manifestations of dehydration (think skin, BP, Pulse rate, urine, neck veins)

A
  • rapid pulse
  • hypotension
  • poor skin turgor
  • elevated body temperature
  • color of Urine
  • I&O
  • flat neck veins
  • Hypernatremia
  • Hypokalemia
21
Q

What is the priority when caring for a child with severe diarrhea?

A

•Drinking lots of fluids because dehydration is the main concern

22
Q

Why does the nurse recommend against straining with defecation? What can it cause?

A
  • Hemorrhoids
  • abnormal heart rhythm
  • may contribute to the development of colorectal cancer.
23
Q

What causes constipation

A
  • Frequent use of laxatives
  • Inadequate fluid intake
  • Inadequate fiber intake
  • Immobilization due to injury
  • ignoring defecation
24
Q

What nursing intervention should be done when a client experiences cramping during the instillation of an enema?

A

•Lower solution container and check the temperature and flow rate. If the solution is too cold or flow rate too fast, severe cramping may occur

25
Q

What is a normal BP reading?

A

Less than 120/Less than 80

26
Q

Prehypertension?

A

120-129/Less than 80

27
Q

Stage 1 Hypertension

A

130-139/80-89

28
Q

Stage 2 Hypertension

A

Great than or equal to 140/Greater than or equal to 90

29
Q

List sources of errors while taking BP measurements

A

•Not use nicotine or drink any caffeine for 30 min
•Rest for 5 min before measurement.
•Sit in a chair, with the feet flat on floor, the back and
arm supported, and the arm at heart level.

30
Q

How does the nurse assess the apical pulse?

A
  • Place diaphragm of stethoscope on chest at the fifth intercostal space at the left midclavicular line
  • If rhythm is regular, count 30 sec & multiply x 2. If rhythm is irregular count for 1 full min.
  • Use this site for assessing the heart rate of an infant
31
Q

What areas can be used to measure oxygen saturation? Why would the nurse use an alternative to the finger?

A
  • finger.

* alternative: earlobe or nose

32
Q

Describe Cheyne-Stokes respirations

A

•Irregular rate and depth of respirations that follow a cyclical pattern. The client will experience shallow breaths that progress to a normal pattern, and increased rate, then the rate begins to slow again, ending with an apneic period.

33
Q

List the steps to taking a tympanic temperature

A
  • for adult pull the ear up and back

* for child 3yr younger pull the ear down and back

34
Q

List 3 non-verbal behaviors that can indicate pain in a client

A
  • grimacing
  • clenching
  • restlessness
35
Q

When first caring for an older adult in a SNF what should be the nurse’s first plan?

A

•assessment: skin, orientation, mobility

36
Q

What is the proper cleansing agent for hands after caring for a client with C-Diff?

A

Soap and water

37
Q

List actions that can contaminate a sterile field

A
  • Once a sterile item touches something that is not sterile, it is considered contaminated.
  • Any partially unwrapped sterile package is considered contaminated.
  • If there is a question about the sterility of an item, it is considered unsterile.
  • The longer the time since sterilization, the more likely it is that the item is no longer sterile.
  • A commercially packaged sterile item is not considered sterile past its recommended expiration date.
  • Once a sterile item is opened or uncovered, it is only a matter of time before it becomes contaminated.
  • The outer 1-in margin of a sterile area is considered a zone of contamination.
  • A sterile wrapper, if it becomes wet, wicks microorganisms from its supporting surface, causing contamination.
  • Any opened sterile item or sterile area is considered contaminated if it is left unattended.
  • Coughing, sneezing, or excessive talking over a sterile field causes contamination.
  • Reaching across an area that contains sterile equipment has a high potential for causing contamination and is therefore avoided.
  • Sterile items that are located or lowered below waist level are considered contaminated because they are not within critical view.
38
Q

What are the steps to pouring a sterile solution onto a piece of gauze.

A
  • pour and discard a small amount from the mouth of the container
  • hold the container in front.
  • Avoid touching any sterile areas within the field.
  • control the height of the container to avoid splashing the sterile field
39
Q

who is the best place to identify assessment data?

A

clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

40
Q

What are nursing short-term goals and give examples

A

(outcomes achievable in a few days to 1 week)
•Bed to chair
•Client will have a bowel movement in 2days
•Moving with in the next few hours

41
Q

What is subjective data and give examples

A

SUBJECTIVE: What the client tells the nurse
Ex: “My shoulder is really, really sore.”

42
Q

What are the levels of Maslow’s hierarchy of human needs

A
  • Self-actualization
  • Self-esteem
  • Love and belonging
  • Safety and security
  • Physiology
43
Q

What are the steps of the nursing process? And give an example of each step

A 
•	Assessment/data collection*
•	Analysis/data collection*
•	Planning
•	Implementation
•	Evaluation
The accuracy and thoroughness of assessment/analysis/data collection and planning have a direct effect on implementation and evaluation. Use of the nursing process results in a comprehensive, individualized client-centered plan of nursing care that nurses can deliver in a timely and reasonable manner.
44
Q

Type of incontinence: Functional

A

Loss of Urine due to factors that interfere with responding to the need to urinate(cognitive, mobility, and environmental barriers)

45
Q

Type of incontinence: Reflex

A

Involuntary loss of a moderate amount of urine
usually without warning due to hyperreflexia of the
detrusor muscle, usually from spinal cord dysfunction.

Fundamental Test 2 (1 decks)

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