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VN 15 FUNDS OF NURSING > VN 15 TEST 2 STUDY GUIDE-DONE > Flashcards

VN 15 TEST 2 STUDY GUIDE-DONE Flashcards

1
Q
  1. What are the four types of incontinence and describe them
A

urge incontinence - uncontrollable urge to urinate several times during the day & night

Overflow incontinence- occurs when you leak or dribble urine because your bladder is too full

Functional incontinence- disability associated urinary incontinence . When the person is unable to access the toilet due to physical or cognitive condition.

Stress incontinence-happens when physical movement or activity — such as coughing, laughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder, causing you to leak urine.

Reflex incontinence- with no warning ,involuntary urination

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2
Q
  1. What is the purpose of a guaiac test?
A

To check for blood in the stool

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3
Q
  1. List nursing interventions for constipation
A
  • Increase fiber & water consumption(unless containdicated) before more invasive interventions
  • Give bulk forming products(laxative like metamucil)before stool softeners, stimulants or suppositories
  • probiotic foods, exercise
  • Give an oil retention enema(last resort)
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4
Q
  1. What would the VN instruct the client to avoid prior to taking an at home FOBT?
A
  1. stop taking NSAIDS(more than 1 adult aspirin ect. For 7 days before self collection
  2. Avoid taking more than 250mg of vitamin c or consuming citrus fruits or juices for 3 days before beginning the test.
  3. Avoid red meats, raw vegetables, fruits,radishes, tunips 2-3 before the test.
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5
Q
  1. What are manifestations of a UTI?
A

Urinary frequency, urgency, nocturia,flank pain,hematuria(blood in the urine),cloudy, foul smelling urine & fever.

In older adults: new onset increased confusion, recent falls, new onset incontinence, anorexia, fever, tachycardia, hypotension.

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6
Q
  1. List instructions to collect a 24-hour urine
A

• Discard the first voiding.
* Collect all other urine. Refrigerate, label, and transport
the specimen.

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7
Q
  1. Define: dysuria; urgency; nocturia, and oliguria
A

Dysuria- difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. (Discomfort when urinating)

Urgency- a strong feeling that urine must be eliminated quickly

Nocturia- frequent urination at night

Oliguria- urine output less than 400 mL in 24 hours, indicates the inadequate elimination of urine. (Low urine output)

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8
Q
  1. Give an example of a good fluid balance when assessing I&Os
A

The amount of fluid going in must come out.

30 ML/hr output

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9
Q
  1. List indications for urinary catheterization
A
  • Relieve urinary retention
  • keeping incontinent clients dry
  • instilling medication within the bladder
  • obtaining sterile urine specimens
  • Assessing fluid balance accurately
  • Keeping the bladder from becoming distended during procedures such as surgery
  • obvious perineal wound
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10
Q
  1. What are diagnostic findings in a UTI?
A

The urine is examined under a microscope for bacteria or white blood cells, which are signs of infection.

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11
Q
  1. List client education when teaching about care for an ileal conduit.
A
  • Change the pouching system every 3-7days week or more to avoid leaks & skin irritation. If there is itching & burning around your stoma its a sign to change pouching system & cleanse skin.
  • Be gentle when removing the pouch system. Peel skin carrier off gently.
  • Don’t remove the pouching system more than once a day unless there is an issue.
  • Cleaning the stoma & skin w/water is enough. If you use soap make sure to rinse well since soap may affect adhesiveness of skin barrier. Pat the skin dry before putting on the skin barrier & pouch.
  • Look out for allergic reactions or sensitivities.
  • empty pouch when its 2/3rd full
  • Making sure that stoma size opening is 1/16 TO 1/8 bigger than the stoma
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12
Q
  1. List assessment of an ileostomy. What color should the stoma be? What instructions should be given regarding medications?
A

Assess skin for evidence of erythema, ulcers, skin integrity.
Gently feel around the stoma site for any tenderness
Ask patient to cough & feel for a cough impulse (assessing for hernias)

The stoma should be bright red & meaty or pink.

DO NOT give enteric coated medications

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13
Q
  1. List manifestations of dehydration (think skin, BP, Pulse rate, urine, neck veins)
A 
Poor skin turgor
dark yellow & strong-smelling urine
Weak, rapid pulse
Hypotension
Elevated body temperature
Flat neck veins
Tachycardia 
oliguria
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14
Q
  1. What is the priority when caring for a child with severe diarrhea?
A

Replace fluid & electrolytes
Monitor for manifestations of dehydration
Provide perineal care after each stool, apply a moisture barrier.

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15
Q
  1. Why does the nurse recommend against straining with defecation? What can it cause?
A

Straining against defecation can cause hemorrhoids, rectal fissures, syncope(fainting), tachycardia, heart dysrethmias,hypotension .

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16
Q
  1. What causes constipation?
A

Immobility, frequent use of laxatives, advanced age, inadequate fluid intake, inadequate fiber intake , sedentary lifestyle, ignoring the urge to deficate,pregnancy & medication effects

17
Q
  1. What nursing intervention should be done when a client experiences cramping during the instillation of an enema?
A

Slow the flow of solution by lowering the container

18
Q
  1. What is a normal BP reading?
A

Less than 120/ less than 80

19
Q

18a. Prehypertension?

A

120-129 /less than 80

20
Q

18b.Stage 1?

A

130-139/ 80-89

21
Q

18c. Stage 2?

A

greater than or equal to 149 / greater than or equal to 90

22
Q
  1. List sources of errors while taking BP measurements
A

Caffeine/Nicotine use, Acute meal ingestion, Full bladder, improper client positioning(legs crossed), wrong size cuffs

23
Q
  1. How does the nurse assess the apical pulse?
A

By auscultating over the 5th intercostal space at the left midclavicular line.

24
Q
  1. What areas can be used to measure oxygen saturation? Why would the nurse use an alternative to the finger?
A

The fingertip, earlobe or bridge of nose.

Use earlobe or bridge of nose for clients who have peripheral vascular disease.

25
Q
  1. Describe Cheyne-Stokes respirations
A

Also known as the death rattle, Irregular rate & depth of respirations that follow a cyclical pattern. Shallow breaths that progress to a normal pattern & increased rate, then the rate begins to slow again, ending with an apneic(not breathing) period.

26
Q
  1. List the steps to taking a tympanic temperature
A

Perform hand hygiene, lift ear up & back (adult) insert thermometer probe w/cover snugly into clients ear canal. You pull the ear down & back for a child. Leave thermometer in place until reading is complete and gently remove thermometer.

27
Q
  1. List 3 non-verbal behaviors that can indicate pain in a client
A

Facial expressions( grimacing, wrinkled forehead)
Body movements(restlessness, pacing, guarding)
Moaning
Crying
Decreased attention span
Increase in blood pressure, pulse & respiratory rate

28
Q
  1. When first caring for an older adult in a SNF what should be the nurse’s first plan?
A

Initial plan generally identifies priority problems & includes the client’s projected needs for teaching & discharge planning.

Assess for skin(head to toe),orientation, mobility

29
Q
  1. What is the proper cleansing agent for hands after caring for a client with C-Diff?
A

Soap & water

30
Q
  1. List actions that can contaminate a sterile field
A

Reaching across or above a sterile field
Turning your back on a sterile field
Putting hands down or above your abdomen region
Touching the outer wrappings & 1 inch edges of packaging of sterile items.
Touching any unsterile materials or fields
Sneezing, coughing or talking directly over a sterile field

31
Q
  1. What are the steps to pouring a sterile solution onto a piece of gauze.
A

*Remove the bottle cap.
*Place the bottle cap face up on a clean (non-sterile) surface
*Hold the bottle with the label in the palm of the hand that the solution does not run down the label
*First pour a small amount (1 to 2 mL) of the solution into an available receptacle.
*Pour the solution (without splashing) onto the dressing or site without touching the bottle to the site.
*Sterile solutions expire 24 hr after opening and recapping in some facilities. Other facilities’ policies state that once a sterile solution container is opened.
can be used only once and then thrown away.

When pouring liquid, do not let the
container that carries the sterile
liquid touch the receptacle.

32
Q
  1. Where or who is the best place to identify assessment data?
A

With the patient themselves.

33
Q
  1. What are nursing short-term goals and give examples
A

Short term goals are things you want client to achieve in a span of the next few hrs. (1hr-3hr) or within your shift

Ex: A client who is experiencing immobility, short term goal would be getting client to reposition in the bed with little assistance.

34
Q
  1. What is subjective data and give examples
A

Subjective data is information the client is providing such as pain level, symptoms, family history etc.

35
Q
  1. What are the levels of Maslow’s hierarchy of human needs?
A
  1. Physiological: air,water, food, shelter, clothing, reproduction
  2. Safety & Security:personal security, employment,resources, health, property
  3. Love & belonging: friendship, intimacy, family,sense of connection
  4. Self- esteem: respect,status,recognition,strength & freedom
  5. Self actualizaiton: Desire to become the most that one can be
36
Q
  1. What are the steps of the nursing process? And give an example of each step
A

(A.D.P.I.E)
Assessment: collect subjective & objective data
Planning: Create short & long term goals that will achieve therapeutic result.
Implement: Nursing actions that can work towards achieving therapeutic results.
Evaluation: determine if goals were achieved.

VN 15 FUNDS OF NURSING (12 decks)

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