Nur1 test 3

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Nur1 test 3
2010-10-20 20:49:19
stuff on test

nursing diagnosis, urinary incontinence
Show Answers:

  1. Define urinary incontinence
    Any involuntary leakage of urine.
  2. S/S of urinary incontinence
    • Dribble,
    • leakage,
    • Pressure causing involuntary void
  3. Risks from incontinence
    • Skin breakdown,
    • Frequent UTI,
    • Social isolation
  4. How is a sterile specimen collected from a catheter?
    Clamp hose, clean port w/ alcohol, take sample with syringe
  5. 24 hr urine procedure
    Throw 1st urine of the day, collect all urine for the next 24 hrs, keep on ice or in refrigerator
  6. Nursing Diagnosis for urinary incontinence
    Social isolation related to urinary incontinence manifested by unwillingness to go out into public
  7. Interventions to assist voiding (male)
    Break Iodine capsules in urinal, have him stand, straight cath, give them privacy, run water
  8. Auscultate for bowel sounds…
    In all four quadrants, until you hear them (up to 5 min each quadrant)
  9. What should you do if no bowel sounds are audible?
    Document and call doctor
  10. How can you reduce anxiety before/during diagnostic procedures?
    Explain the procedure
  11. What should be assessed post colon surgery?
    Bowel Sounds
  12. Nursing diagnosis for diarrhea
    Fluid imbalance r/t diarrhea manifested by…dark urine, reduced skin turgor, loose/watery stools.
  13. What type of stool will come from a colostomy?
  14. Pt.’s at risk for respiratory illness…
    Immobility, age, occupation, recent surgery, where they live, illnesses
  15. What does pulse ox measure?
    % of oxygen on each hemoglobin in the arterial blood.
  16. What position facilitates respirations?
  17. What is the purpose of pursed-lip breathing?
    • Blows off CO2,
    • Prolongs expiration to decreasing collapse of alveoli,
    • Reduces airway constriction.
  18. How are bronchodilators administered?
    Inhalers & nebulizers
  19. Define negligence…
    Failure to perform a task that puts a pt. at risk
  20. What is the best defense for negligence?
    Document, document, document
  21. Define assault…
    Aggressive behavior towards another (verbal/physical)
  22. Define damages (in malpractice)
    Damage to a pt.; What happened to the pt. (physically, monetarily, emotionally)
  23. What is a nursing diagnosis for physical effects dehydration & infection?
    Increased body temperature r/t dehydration & infection manifested by a temp of 103.4
  24. What is the desired action of inhalation anesthesia?
  25. What is the nurse’s role in consent?
    Witness pt.’s signature. *The person performing procedure is responsible for answering any questions & pt. teaching*
  26. Nursing diagnosis for someone that is overweight & recently undergone abdominal surgery…
    Infection, decrease circulation, dehiscence (wound split open) r/t…
  27. What is the nursing action to low potassium (just prior to having surgery)
    Document and call doctor
  28. Patient teaching to cough effectively after surgery…
    Splint incision site,
  29. Purpose of assessment in PACU
    To assess for complications with surgery, ABCs
  30. Nursing action for post-surgery bleeding…
    Pressure and report findings
  31. Where should your check for bleeding post-surgery other then incision site?
    Posterior of site, where gravity will draw the blood.
  32. Define unintentional wound…
    Jagged edges, higher risk for infection, more blood loss
  33. Rational for semi-fowlers r/t respiratory…
    Helps with lung expansion
  34. What is some patient teaching post-surgery?
    Follow-up, about medications, avoid driving, avoid signing legal documents
  35. What is an important patient teaching to prevent infection?
    Wash hands
  36. What are DRG’s
    Diagnostic Related Group; Determines the time and amount of money given to hospital for a certain illness.
  37. Who can be admitted to a long term facility?
    Anyone who qualifies regardless of age.
  38. How can nurses shape health reform?
    Be politely active, don’t reelect Obama
  39. What information to pt. does HIPPA mandate?
    How your information will be shared.
  40. What is the rational for discharge planning?
    Continuity of care.
  41. What are some signs of invasion of personal space?
    Backing away, putting up hands, they look away
  42. Define empathetic…
    A non-judgmental approach to “feel for them”
  43. How can you help build relationships with pt. during orientation phase?
    Introduce yourself by your name, call them by their name/ ask them their preferred name.
  44. What is autocratic leadership?
    A dictatorship, where one person dictates what to be done w/o consideration of other’s opinions/observations
  45. Why give Lasix and aldactone together?
    To help maintain an electrolyte balance.
  46. What should you do if pt. requests a medication they have no order for?
    Call doctor about getting an order before administering
  47. Examples of medication errors…
    • Wrong:
    • Patient
    • Dose
    • Route
    • Time
    • Reason