VN 15 Study Guide 2

Question 1

What are the four types of incontinence and describe them

Answer 1

• 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

Question 2

The loss of small amounts of urine when intra-abdominal pressure rises

Answer 2

Type of incontinence: Stress

Question 3

Need to void perceived frequently with short-live ability to sustain control of the flow

Answer 3

Type of incontinence: Urge

Question 4

Loss of urine without any identifiable pattern or warning

Answer 4

Type of incontinence: Total

Question 5

Urine leakage because the bladder is not completely emptied; bladder distended with retained urine

Answer 5

types of incontinence: Overflow

Question 6

What is the purpose of a guaiac test?

Answer 6

Detects blood in the stool

Question 7

List nursing interventions for constipation

Answer 7

*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

Question 8

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

Answer 8

• 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

Question 9

What are manifestations of a UTI?

Answer 9

• Urinary frequency, urgency, nocturia, flank pain, hematuria
• dark amber
• cloudy
• foul-smelling urine
• fever.
• hypotension.

Question 10

List instructions to collect a 24-hour urine

Answer 10

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

Question 11

difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. Frequency and urgency often accompany

Answer 11

Dysuria

Question 12

(a strong feeling that urine must be eliminated quickly) often accompany dysuria.

Answer 12

Urgency

Question 13

(nighttime urination) is unusual because the rate of urine production is normally reduced at night.

Answer 13

Nocturia

Question 14

urine output 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

30ml/hr

Question 16

List indications for urinary catheterization

Answer 16

• 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)

Question 17

What are diagnostic findings in a UTI?

Answer 17

• 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

Question 18

List client education when teaching about care for an ileal conduit.

Answer 18

• 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.

Question 19

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

Answer 19

• 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..

Question 20

List manifestations of dehydration (think skin, BP, Pulse rate, urine, neck veins)

Answer 20

• rapid pulse
• hypotension
• poor skin turgor
• elevated body temperature
• color of Urine
• I&O
• flat neck veins
• Hypernatremia
• Hypokalemia

Question 21

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

Answer 21

•Drinking lots of fluids because dehydration is the main concern

Question 22

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

Answer 22

• Hemorrhoids
• abnormal heart rhythm
• may contribute to the development of colorectal cancer.

Question 23

What causes constipation

Answer 23

• Frequent use of laxatives
• Inadequate fluid intake
• Inadequate fiber intake
• Immobilization due to injury
• ignoring defecation

Question 24

What nursing intervention should be done when a client experiences cramping during the instillation of an enema?

Answer 24

•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

Question 25

What is a normal BP reading?

Answer 25

Less than 120/Less than 80

Question 26

Prehypertension?

Answer 26

120-129/Less than 80

Question 27

Stage 1 Hypertension

Answer 27

130-139/80-89

Question 28

Stage 2 Hypertension

Answer 28

Great than or equal to 140/Greater than or equal to 90

Question 29

List sources of errors while taking BP measurements

Answer 29

•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.

Question 30

How does the nurse assess the apical pulse?

Answer 30

* 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

Question 31

What areas can be used to measure oxygen saturation? Why would the nurse use an alternative to the finger?

Answer 31

* finger. | * alternative: earlobe or nose

Question 32

Describe Cheyne-Stokes respirations

Answer 32

•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.

Question 33

List the steps to taking a tympanic temperature

Answer 33

* for adult pull the ear up and back | * for child 3yr younger pull the ear down and back

Question 34

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

Answer 34

* grimacing * clenching * restlessness

Question 35

When first caring for an older adult in a SNF what should be the nurse’s first plan?

Answer 35

•assessment: skin, orientation, mobility

Question 36

What is the proper cleansing agent for hands after caring for a client with C-Diff?

Answer 36

Soap and water

Question 37

List actions that can contaminate a sterile field

Answer 37

* 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.

Question 38

What are the steps to pouring a sterile solution onto a piece of gauze.

Answer 38

* 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

Question 39

who is the best place to identify assessment data?

Answer 39

clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

Question 40

What are nursing short-term goals and give examples

Answer 40

(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

Question 41

What is subjective data and give examples

Answer 41

SUBJECTIVE: What the client tells the nurse Ex: "My shoulder is really, really sore.”

Question 42

What are the levels of Maslow’s hierarchy of human needs

Answer 42

* Self-actualization * Self-esteem * Love and belonging * Safety and security * Physiology

Question 43

What are the steps of the nursing process? And give an example of each step

Answer 43

``` • 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. ```

Question 44

Type of incontinence: Functional

Answer 44

Loss of Urine due to factors that interfere with responding to the need to urinate(cognitive, mobility, and environmental barriers)

Question 45

Type of incontinence: Reflex

Answer 45

Involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction.