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Nursing > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

what unit do you measure urine in?

A

mL

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2
Q

what characteristics should you document in relation to urine?

A

color, clarity, smell,

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3
Q

what is included in intake?

A

oral fluids, IV fluids, ice

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4
Q

how much intake is required everyday?

A

6-8 8OZ CUPS
2L

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5
Q

how many mL is 1 fluid oz

A

30mL

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6
Q

what is the ratio of volume for ice to wate?

A

Ice is half the volume of water

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7
Q

what is considered output?

A

blood, urine, bowel, emesis, drainage

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8
Q

how many grams is one mL

A

1 gram to 1mL

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9
Q

What is included in a urine history assesment?

A

pattern changes, weight changes

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10
Q

what is included in a urine assessment under problems?

A

frequency, urgency, difficulty starting, nocturia

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11
Q

what existing problems should be considered under a urine assessment?

A

medications and comorbidities

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12
Q

what characteristics should you document under assessment for urine?

A

color…should be straw to clear
odor
floaters

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13
Q

what do muscles do?

A

create movement, maintain posture, stabilization

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14
Q

do muscles support soft tissues like organs?

A

yes through the abdominals

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15
Q

what do muscles do in terms of thermoregulation?

A

create heat

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16
Q

what does the nervous system do?

A

causes purposeful movement

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17
Q

what is anatomical position?

A

facing forward, palms forward,

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18
Q

what is abduction?

A

moving part away from the midline

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19
Q

what is adduction?

A

moving towards midline

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20
Q

what happens to the angle when going into extension?

A

angle increases

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21
Q

what happens to the angle in flexion?

A

angle decreases

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22
Q

what is rotation?

A

moving a body part 360 degrees without creating a circle

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23
Q

what is circumduction?

A

moving something in a circular motion

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24
Q

what is internal rotation?

A

spinning inward

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25
Q

what is external rotation?

A

spinning outward

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26
Q

what two body parts can rotate and circumduct?

A

xx

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27
Q

what is plantar flexion?

A

pointing toes down

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28
Q

what is dorsiflexion?

A

pointing feet up

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29
Q

what is hyperextension?

A

extended something and extended beyon that

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30
Q

what is pronation?

A

palms facing behind

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31
Q

what is supination?

A

palms facing forward

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32
Q

oppostion?

A

all fingers touching thumb

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33
Q

what is inversion?

A

arch goes up….sole towards body midline

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34
Q

what is eversion?

A

arch goes down….sole away from body of midline

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35
Q

what does development do as a factor affecting movement?

A

age and a musclular development……baby….teen…adult….elderly

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36
Q

what does physical healthy do as a factor affecting movement?

A

muscles…..disorders….. arthritis….CHF

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37
Q

what does mental health do as a factor affecting movement?

A

depression….less energy

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38
Q

what does lifestyle do as a factor affecting movement?

A

what you do in your free time….sedentary vs active

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39
Q

what does attitude and values do as a factor affecting movement?

A

someone who goes to the gym or exercises

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40
Q

what does fatigue/stress do as a factor affecting movement?

A

this effects energy levels

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41
Q

what does external factors do as a factor affecting movement?

A

weather…finances….unsafe neighborhood

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42
Q

what are the effects of exercise on cardiovascular?

A

increased heart efficieny….decrease heart rate and BP….increased blood flow and oxygenation

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43
Q

what are the effects of exercise on respiratory?

A

increased depth of respiration….increased rate…improved gas exchange….improved rate of CO2 excretion

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44
Q

what are the effects of exercise on GI?

A

increased appetite and intestinal tone

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45
Q

what are the effects of exercise on skin?

A

increased circulation

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46
Q

what are the effects of immobility on cardiovascular?

A

increased cardiac workload…increased risk for orthostatic hypotension

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47
Q

what are the effects of immobility on respiratory?

A

decresed depth and rate of respiration…..pooling of secretion…impaired gas exchange

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48
Q

what are the effects of immobility on GI?

A

disturbance in appetite…..decreased food intake…alterations in protien metabolism….poor digestion…constipation

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49
Q

what are the effects of immobility on skin?

A

impaired circulation….skin breakdown

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50
Q

what does immobility do to peristalsis

A

decreased peristalsis

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51
Q

how often should you reposition patient?

A

2 hours

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52
Q

what is part of the patient history in regards to movement?

A

daily activity level….endurance…..exerciise….external factors affecting mobility

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53
Q

what is the physical assessment in regards to movement?

A

ease of movement…gait…posture…alignment… joint structure…. strength…muscle mass…tone…endurance

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54
Q

how do you implement in adults?

A

fintess counseling….clarify misconceptions….desing and moninter safe exercises….

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55
Q

how do you implement in older audlts

A

teach and counsel about
need for regular exercise……need for high protein, calcium, and vitamin D….pacing activities….use assistive devices….safety proof home

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56
Q

when do you need two people to transfer?

A

when you patient is more than 35lbs

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57
Q

what does the ability to assist mean in regard to transfer?

A

can they help

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58
Q

what does tools mean in regard to transfer?

A

using lifts…gait belt….

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59
Q

what does area mean in regard to transfer?

A

clutter and things around

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60
Q

what does the ability to understand mean in regard to transfer?

A

can the patient understand what you are going to do

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61
Q

what should you do when performing a safe transfer?

A

plan…communiate…treat pain…elevate workspace…lock wheels…body alignment…body support…avoid friction…smooth movements….appropriate equipment….document

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62
Q

what are some patient transfer assistive devices

A

gait belt….standing assist….lateral assist/slide… friction-reducing sheets….mechanical lateral assist…transfer chair….powered stand assist chair…powered full-body lifts

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63
Q

what are transfer techniques for nurses

A

draw sheets…log rolling…bed to char

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64
Q

what is fowlers position?

A

45 to 90 degrees

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65
Q

what is supine?

A

flat on back

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66
Q

what is prone?

A

flat on stomach

67
Q

what is sims position?

A

on the side with top leg in front and top shoulder forward

68
Q

what is side lying or lateral?

A

on side with knees stacked and shoulder stacked

69
Q

what are some positioning devices?

A

the foam wedge… mattresses…adjustable bed… trapeze bar…foot support….hip and leg support…hand and wrist support…side rails

70
Q

what are mobility aids for waling

A

walker…..cane…crutches…braces

71
Q

what side should your cane be on?

A

crutch should be on strong side

72
Q

what are the steps to walking with a cane?

A

move cane forward and then move weak side and then move strong side

73
Q

what are the steps to use a walker

A

move the walker forward….then the weak foot…then the strong foot

74
Q

how far should top of crutch be from armpit

A

1 to 2 inches

75
Q

how far should foot be from the foot of the crutch?

A

12 inches

76
Q

how far should cane be from foot?

A

4 inches

77
Q

what angle should your elbow be for walker

A

15 degrees

78
Q

what is isotonic exercise?

A

shortening and moving of a muscles with no resistance

79
Q

what is isometric exercise?

A

contraction with no relaxation

80
Q

what is isokenetic?

A

muscles contraction with resistance

81
Q

what is aerobic exercise

A

improves heart rate and blood flow

82
Q

what is stretching?

A

moving muscles through the range of motion

83
Q

what is strength and endurance

A

building muscle mass and strength

84
Q

ADLs

A

things done in the home

85
Q

what is active range of motion?

A

when you move your own joint

86
Q

what is passive range of motion?

A

when you have someone help in range of motion

87
Q

where should you support joint?

A

above and below the join

88
Q

how often should ROM be done?

A

ROM exercise twice a day

89
Q

what do the kidney do?

A

remove waste products from blood and produce urine

90
Q

what does the ureter do?

A

takes urine from the kidney and stores in the bladder

91
Q

what does the bladder do?

A

stores urine

92
Q

what is urine incontinence?

A

the inability to control the release of urine…different levels

93
Q

what are complicatins of incontinence?

A

UTI….skin breakdown….mental health

94
Q

what education should be provided to incontinent patients?

A

drink only beyween 0600 and 1800

limit alcohol, caffeine, and citrus

take diuretics in the morning

kegal exercises

95
Q

what nursing care should be done for incontinent patients?

A

peri care and clean linens

96
Q

what is urine retention?

A

holding onto urin

97
Q

what are the complications of retention?

A

UTI….distened bladder…kidney infection…overstretching of bladder`

98
Q

what education should be provided to those holding urine?

A

stay hydrated….go when you have to

99
Q

what nursing care should be provided to patients with urine retention?

A

sit patients up pee……privacy…give them time….schedule

100
Q

what is a in and out catheter?

A

a cath that is used for acute retention…sterile collection…or spinal chord injuries

101
Q

what is a foley cath?

A

a catheter that stays in place for a extended period of time

102
Q

how often should foley be changed????

A

xxx

103
Q

what is a coude?

A

a catheter that has a curved rigid tip…used for males with enlarged prostate

104
Q

what is a suprapubic catheter?

A

catheter that inserts directly into the bladder from the pubic region

105
Q

what is a condom catheter?

A

for males….less invasive….change every 24 hours…leave 1-2 inches from tip of penis to the tip of condom cath

106
Q

what is a pure wick

A

for females…less invasive…change every 24 hours….top 1/3 needs to be over urethral opening…suction needs to be no more than 40….can be used during menstration

107
Q

what is a urinnalysis?

A

can come from bedpan, hat, or urinal…..not sterile…looks at lab levels

108
Q

what is a urine culture?

A

sterile….shows infections in urine

109
Q

what does the esophagus do?

A

takes food from mouth to stomach

110
Q

what does the stomach do?

A

mixes food and liquid with digestive juices

111
Q

what does the duodenum of the small intestine do?

A

It absorbs nutrients like vitamins, minerals, carbohydrates, fats, proteins and water from food to be used by the boddy

112
Q

what does the jejunum of the small intestine do?

A

absorb sugars, amino acids, and fatty acids

113
Q

what does the ileum of the small intestine do?

A

major absorptive products being vitamin B12 and bile acids.

114
Q

what does the large intestine do?

A

turns the liquid digested food into solid stool

115
Q

what does the ascending colon do?

A

absorbs water from stool

116
Q

what does the transverse colon do?

A

absorbs water from stool

117
Q

what does the desceding colon do?

A

stores stool

118
Q

what should the abdomen look like during an assessment?

A

should be flat, soft, and not tender

Also should be bowel sounds

119
Q

what history should you gather in regards to fecal?

A

patterns, color, form, diet, stress, GI bleed

120
Q

do meds change your bowle habbits?

A

yes

121
Q

is bleeding a concern in bowel?

A

yes

122
Q

what problems are involved in bowel movement?

A

constipation and diarrhea

123
Q

what is diarrhea?

A

3 or more loose stools a day

124
Q

what complications arise from diarrhea?

A

dehydration, nausea, vomiting

125
Q

what education should be provided those who have diarrhea?

A

drink water, avoid caffeine and alcohol

126
Q

what should nurses do for those who have diarrhea?

A

administer fluids/electrolytes, look for symptoms of dehydration

127
Q

what is constipation?

A

hard to pass stool…..dry….hard

128
Q

what is the complication with constipation?

A

impaction….neausea and vomitting

129
Q

what education needs to be provided to those who are experiencing constipation

A

need to drink fluids….2L of water

Eat 25-30g of fiber per day

Exercise

130
Q

what nursing care needs to be provided to those who have constipation?

A

oral fluids and IV fluids….walking….balanced diet

131
Q

what are the two kinds of enemas?

A

saline enema or oil enema

132
Q

what position muse a patient be in to do an enema?

A

left lateral

133
Q

how long should someone hold a saline enema?

A

15 minutes

134
Q

how long should someone hold a oil enema?

A

30-60 minutes

135
Q

how many mL is a oil enema?

A

150 to 200

136
Q

how many mL is a saline enema?

A

500 - 1000

137
Q

how does a saline enema work?

A

distends intesines, lubricates stool, and irritates bowel

138
Q

how does a oil based enema work?

A

lubricates everything

139
Q

what position should a patient be in when getting an enema?

A

left lateral

140
Q

what does a stool culture show?

A

sterile procedure that shows infection present

141
Q

what does a fecal occult blood test show?

A

if blood is present

142
Q

what is a colostomy?

A

diversion of intestines through skin

143
Q

why do people have colostomy?

A

when lifestyle changes dont fix bowel habbits….cancer…surgery

144
Q

what should a stoma look like?

A

red, moist, and painless

145
Q

when should you be worried about stoma?

A

dry, wrong color, painful

146
Q

when should a colo bag be emptied?

A

1/3 to 1/2 full

147
Q

what education can be provided to those with colostomy bags?

A

support groups and how to take care of it

148
Q

what is a healthy weight?

A

a weight that can be maintaned with the number of calories burned

149
Q

fat in the abdomen makes you susceptible to what kind of disease?

A

hypertension, diabetes, stroke, and cardiovascular problems

150
Q

what are the three nutrient food groups?

A

carbs….fats…protien

151
Q

what does the body use carbs for?

A

converted to glucose and used for energy

152
Q

what are proteins used for?

A

form genes and enzymes…..good for muscles, skin, blood…..essential for the body

153
Q

what are fats used for?

A

used to store energy, absorb nutrients, and used in hormones

154
Q

are fats soluble in blood and water?

A

no

155
Q

what are examples of vitamins?

A

Vitamin D, C, B

156
Q

where are vitamins found?

A

from fresh foods

157
Q

what is the ranking for vitamin content?

A

Fresh, Frozen, canned

158
Q

what do vitamins do?

A

vitamins help you resist infections and keep your nerves healthy, while others may help your body get energy from food or help your blood clot properly

159
Q

what are examples of minerals?

A

copper, zinc, sodium

160
Q

what do minerals do?

A

building strong bones and teeth. controlling body fluids inside and outside cells. turning the food you eat into energy

161
Q

what percentage of bod weight is water?

A

50-60

162
Q

what is more important water or food?

A

water

163
Q

what is a good split between carbs, proteins, and fats

A

carbohydrates 45–65%
fat 25–35%
protein 10–30%

Nursing (18 decks)

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