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VN15 & VN17 Study Guides > VN 15 Study Guide Test 2 > Flashcards

VN 15 Study Guide Test 2 Flashcards

1
Q

What are the four types of incontinence

A

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

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2
Q

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

A

Stress incontinence

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3
Q

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

A

Urge incontinence

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4
Q

Periodic, involuntary urination

A

Reflex

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5
Q

Control over urine lost

A

Functional

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6
Q

What is the purpose of a guaiac test

A

Checking for occult blood in stool

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7
Q

List nursing interventions for constipation

A

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

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8
Q

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

A 
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
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9
Q

What are manifestations of a UTI

A 
Dark urine color 
Amber color 
Cloudy 
Unpleasant odor 
Fever
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10
Q

List instructions to collect a 24 hour urine

A
  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
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11
Q

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

A

Dysuria

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12
Q

A strong feeling that urine must be eliminated quickly

A

Urgency

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13
Q

Nocturia

A

Nighttime urination

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14
Q

Is urine output that is 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

500-3000ml a day output

2 liters a day input

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16
Q

List indications for urinary cathetreization

A

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

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17
Q

What are diagnostic findings in a UTI

A

White blood cells, leukocytes, and blood

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18
Q

List client education when teaching about care for an ileal conduit

A
  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
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19
Q

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

A

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

20
Q

List manifestations of dehydration

A 
Skin tugor/elasticity 
Hypotension 
Dark urine 
Distended veins *
Oliguria
Tachycardia
Pulse rate increased
21
Q

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

A

To prevent dehydration

22
Q

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

A

Hemorrhoids
Fainting
Disarythmia, abnormal heart rate

23
Q

What causes constipation

A 
Inadequate fiber
Excessive laxative use
Ignore urge to defecate 
Low fluid/fiber intake 
Immobility
24
Q

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

A

Lower height of solution container

25
Q

Normal BP reading

A

120/80

26
Q

Prehypertension

A

120-139 80/89

27
Q

Stage 1: hypertension

A

130-139

80-90

28
Q

Stage 2: hypertension

A

140/90 or greater

29
Q

List sources of errors while taking BP measurements

A

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

30
Q

How does the nurse assess the apical pulse?

A

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

31
Q

What areas can be used to measure oxygen saturation?

A

bridge of nose, ears, finger

32
Q

Why would the nurse use alternative to the finger

A

Nail polish, no fingers

33
Q

Describe Cheyenne-stokes respirations

A

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

34
Q

List steps to taking tympanic temperature

A

Pull ear up and back

Twist & then insert with circular motions

35
Q

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

A

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

36
Q

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

A

Assess skin, MOBILITY, and orientation

37
Q

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

A

Wash hands with soap and water

38
Q

List actions that can contaminate a sterile field

A

A puncture, moisture, tear that passes through sterile field

39
Q

What are the levels of Maslows hierarchy of human needs

A 
1st level: psychological
2nd level: safety/security 
3rd level: love and belonging 
4th level: esteem and self esteem 
5th level: self actualization
40
Q

Steps for nursing process

A 
Assessment 
Diagnosis
Planning
Implementation 
Evaluate
41
Q

Subjective data

A

Patients words

42
Q

Objective data

A

What nurse observes

43
Q

Leaking urine

A

Overflow incontinence

44
Q

Client education when caring for a client with a Ileal Conduit

A

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

45
Q

Steps to pouring sterile solution onto a gauze

A
  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

VN15 & VN17 Study Guides (4 decks)

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