VN 15 Study Guide Test 2

Question 1

What are the four types of incontinence

Answer 1

A. Stress
B. Urge
C. Reflex
D. Functional

Question 2

Loss of small amounts of urine when intra-abdominal pressure rises

Answer 2

Stress incontinence

Question 3

Need to void perceived frequently with short iced ability to sustain control of flow

Answer 3

Urge incontinence

Question 4

Periodic, involuntary urination

Answer 4

Reflex

Question 5

Control over urine lost

Answer 5

Functional

Question 6

What is the purpose of a guaiac test

Answer 6

Checking for occult blood in stool

Question 7

List nursing interventions for constipation

Answer 7

A. Give oil retention enema, PRN
B. Laxative
C. Encourage 8-10 glasses of fluid per day; offer prune or apple juice
D. Educate about high fiber foods and intake should increase as tolerated

Question 8

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

Answer 8

No Aspirin/ibuprofen 
No vitamin C
Eat high fiber diet
No red meat for 3 days before test 
Don’t eat raw turnips, radishes, broccoli, beets, carrots, cauliflower, cucumbers or mushrooms 3 days to test

Question 9

What are manifestations of a UTI

Answer 9

Dark urine color 
Amber color 
Cloudy 
Unpleasant odor 
Fever

Question 10

List instructions to collect a 24 hour urine

Answer 10

1. Instruct client to urinate before test and then discard urine
2. Exactly 24 hours later, the nurse asks the client to void one last time to compare test collection
3. Final urination is collected, nurse labels and sends to lab

Question 11

Difficulty or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection

Answer 11

Dysuria

Question 12

A strong feeling that urine must be eliminated quickly

Answer 12

Urgency

Question 13

Nocturia

Answer 13

Nighttime urination

Question 14

Is urine output that is less than 400 ml in 24 hours, indicates the inadequate elimination of urine

Answer 14

Oliguria

Question 15

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

Answer 15

500-3000ml a day output

2 liters a day input

Question 16

List indications for urinary cathetreization

Answer 16

Urinary retention *
Measure residual urine after urination
Present or obvious perineal wound

Question 17

What are diagnostic findings in a UTI

Answer 17

White blood cells, leukocytes, and blood

Question 18

List client education when teaching about care for an ileal conduit

Answer 18

1. Change the pouching system once a week or more to avoid leaks and skin irritation
2. Be gentle when removing the pouch system
3. Cleaning the stoma and skin with water is enough
4. Look out for allergic reactions or sensitivities

Question 19

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

Answer 19

Assess the skin for rashes, redness, scratching or bruising.
The stoma should be red or pink, shiny and moist.
Medications; enteric coated tablets and sustained release products are to be avoided

Question 20

List manifestations of dehydration

Answer 20

Skin tugor/elasticity 
Hypotension 
Dark urine 
Distended veins *
Oliguria
Tachycardia
Pulse rate increased

Question 21

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

Answer 21

To prevent dehydration

Question 22

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

Answer 22

Hemorrhoids
Fainting
Disarythmia, abnormal heart rate

Question 23

What causes constipation

Answer 23

Inadequate fiber
Excessive laxative use
Ignore urge to defecate 
Low fluid/fiber intake 
Immobility

Question 24

What nursing intervention should be done when a client experiences cramping during installation of an edema?

Answer 24

Lower height of solution container

Question 25

Normal BP reading

Answer 25

120/80

Question 26

Prehypertension

Answer 26

120-139 80/89

Question 27

Stage 1: hypertension

Answer 27

130-139 | 80-90

Question 28

Stage 2: hypertension

Answer 28

140/90 or greater

Question 29

List sources of errors while taking BP measurements

Answer 29

Improper cuff size, full bladder, cuff placed incorrectly, legs crossed

Question 30

How does the nurse assess the apical pulse?

Answer 30

Left of sternum at interspace below the fifth rib in midline with the clavicle with a stethoscope

Question 31

What areas can be used to measure oxygen saturation?

Answer 31

bridge of nose, ears, finger

Question 32

Why would the nurse use alternative to the finger

Answer 32

Nail polish, no fingers

Question 33

Describe Cheyenne-stokes respirations

Answer 33

Gradually increases, followed by a gradual increase then by a gradual decrease, then a period when breathing stops briefly before resuming the pattern again

Question 34

List steps to taking tympanic temperature

Answer 34

Pull ear up and back | Twist & then insert with circular motions

Question 35

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

Answer 35

Facial grimaces , clenching teeth or clenching, rocking back and forth lots of movement *restlessness

Question 36

When caring for an older cult in an SNF , what should be the nurses first plan

Answer 36

Assess skin, MOBILITY, and orientation

Question 37

What is the proper cleansing agent for hands after caring for a client with C diff

Answer 37

Wash hands with soap and water

Question 38

List actions that can contaminate a sterile field

Answer 38

A puncture, moisture, tear that passes through sterile field

Question 39

What are the levels of Maslows hierarchy of human needs

Answer 39

``` 1st level: psychological 2nd level: safety/security 3rd level: love and belonging 4th level: esteem and self esteem 5th level: self actualization ```

Question 40

Steps for nursing process

Answer 40

``` Assessment Diagnosis Planning Implementation Evaluate ```

Question 41

Subjective data

Answer 41

Patients words

Question 42

Objective data

Answer 42

What nurse observes

Question 43

Leaking urine

Answer 43

Overflow incontinence

Question 44

Client education when caring for a client with a Ileal Conduit

Answer 44

Making sure trim of opening of seal is 1/16 to 1/8 inch Should be emptied 2/3 full Changed every 3 to 7 days Should be red , pink color

Question 45

Steps to pouring sterile solution onto a gauze

Answer 45

1. Open bottle cap face up 2. Bottle with label facing in palm just in case spill it wont cover the label 3. Pour into recipricle, don’t splash 4. Dip gauze