VN 15 Study Guide 2 Flashcards
What are the four types of incontinence and describe them
• 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
The loss of small amounts of urine when intra-abdominal pressure rises
Type of incontinence: Stress
Need to void perceived frequently with short-live ability to sustain control of the flow
Type of incontinence: Urge
Loss of urine without any identifiable pattern or warning
Type of incontinence: Total
Urine leakage because the bladder is not completely emptied; bladder distended with retained urine
types of incontinence: Overflow
What is the purpose of a guaiac test?
Detects blood in the stool
List nursing interventions for constipation
*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
What would the VN instruct the client to avoid prior to taking an at home FOBT?
- 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
What are manifestations of a UTI?
- Urinary frequency, urgency, nocturia, flank pain, hematuria
- dark amber
- cloudy
- foul-smelling urine
- fever.
- hypotension.
List instructions to collect a 24-hour urine
- Discard the first voiding.
- Collect all other urine.
- Refrigerate, label
- transport the specimen.
difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. Frequency and urgency often accompany
Dysuria
(a strong feeling that urine must be eliminated quickly) often accompany dysuria.
Urgency
(nighttime urination) is unusual because the rate of urine production is normally reduced at night.
Nocturia
urine output less than 400 mL in 24 hours, indicates the inadequate elimination of urine
Oliguria
Give an example of a good fluid balance when assessing I&Os
30ml/hr
List indications for urinary catheterization
- 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)
What are diagnostic findings in a UTI?
- 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
List client education when teaching about care for an ileal conduit.
- 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.
List assessment of an ileostomy. What color should the stoma be? What instructions should be given regarding medications?
- 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..
List manifestations of dehydration (think skin, BP, Pulse rate, urine, neck veins)
- rapid pulse
- hypotension
- poor skin turgor
- elevated body temperature
- color of Urine
- I&O
- flat neck veins
- Hypernatremia
- Hypokalemia
What is the priority when caring for a child with severe diarrhea?
•Drinking lots of fluids because dehydration is the main concern
Why does the nurse recommend against straining with defecation? What can it cause?
- Hemorrhoids
- abnormal heart rhythm
- may contribute to the development of colorectal cancer.
What causes constipation
- Frequent use of laxatives
- Inadequate fluid intake
- Inadequate fiber intake
- Immobilization due to injury
- ignoring defecation
What nursing intervention should be done when a client experiences cramping during the instillation of an enema?
•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
What is a normal BP reading?
Less than 120/Less than 80
Prehypertension?
120-129/Less than 80
Stage 1 Hypertension
130-139/80-89
Stage 2 Hypertension
Great than or equal to 140/Greater than or equal to 90
List sources of errors while taking BP measurements
•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.
How does the nurse assess the apical pulse?
- 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
What areas can be used to measure oxygen saturation? Why would the nurse use an alternative to the finger?
- finger.
* alternative: earlobe or nose
Describe Cheyne-Stokes respirations
•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.
List the steps to taking a tympanic temperature
- for adult pull the ear up and back
* for child 3yr younger pull the ear down and back
List 3 non-verbal behaviors that can indicate pain in a client
- grimacing
- clenching
- restlessness
When first caring for an older adult in a SNF what should be the nurse’s first plan?
•assessment: skin, orientation, mobility
What is the proper cleansing agent for hands after caring for a client with C-Diff?
Soap and water
List actions that can contaminate a sterile field
- 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.
What are the steps to pouring a sterile solution onto a piece of gauze.
- 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
who is the best place to identify assessment data?
clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.
What are nursing short-term goals and give examples
(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
What is subjective data and give examples
SUBJECTIVE: What the client tells the nurse
Ex: “My shoulder is really, really sore.”
What are the levels of Maslow’s hierarchy of human needs
- Self-actualization
- Self-esteem
- Love and belonging
- Safety and security
- Physiology
What are the steps of the nursing process? And give an example of each step
• 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.
Type of incontinence: Functional
Loss of Urine due to factors that interfere with responding to the need to urinate(cognitive, mobility, and environmental barriers)
Type of incontinence: Reflex
Involuntary loss of a moderate amount of urine
usually without warning due to hyperreflexia of the
detrusor muscle, usually from spinal cord dysfunction.
