Exam 3 Rewiew
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Define urinary incontinence?
Loss or lack of bladder control.
Signs/ symptoms of urinary incontinence?
Dribbling, leakage, & abdominal pressure.
Urinary retension increases risk for uti infection.
Risks for incontinence?
Skin break down, and frequent uti infections.
How is sterile specimen collected from a catheter?
Clamp, wait 5-10 min., swab port with alchol, and with draw with needle toward the bladder.
24 hr. urine specimen pecedure?
Toss first urine, collect over 24 hr. put on ice. If one urination is miss must be started over.
Nursing Diagnosis for urinary incontinence?
Social isolation, related to unwillingness to go out in public situations, and manifested by loss of bladder control.
Interventions to assist voiding?
Ammonia capsule broke in urinal (for Men), shower or run water ( for sound), stand up, pore warm water over privates, give privacy, or strait catheter.
Ausculatate bowel sounds?
No audible sounds- nursing actions?
3-5 minutes each of 4 quadrants, or 20 minutes total.
Document, and call doctor.
Diagnostic procedures: Decrease anxiety, How?
Explain it, talk to them.
Food pyramid: What are the food groups requirements?
Fruits, vegatables, dairy, fiber, fats, meats (protein), and fluids.
Post colon surgery: what is accessed.
Bowel sounds, and incision.
If no farting and no bowel sounds, is very bad.
Nursing diagnosis for diarrhea?
Fluid imbalance, related to diarrhea, manifisted by dark urine, diarrhea, skin turgor, etc.
Colostomy: what type of stool?
Patients at risk for respitory illness?
Age, immobility, asphma, surgery, and occupation.
Pollution, and area.
Pulse ox measures what?
Afterial Oxygen % of 02 on hemoglobin.
ABG=Arterial Blood Gas
What position facilitates respirations?
What is the purpose of pursed-lip breathing?
Blows off CO2, expands lungs, and reduces airway resistance.
What is the best defence?
Failing to perform a task, that puts patient at risk.
Exp. patient falls.
Document very well.
Aggresive behavior, verbal, or physical.
Exp. If you don't take those medications, I will ....!!!!
Define damages in malpractice?
Sueing for damages to patient. Something happens or happened to patient.
Exp. Physical, monitary, or emotional.
Dehydration and infection:
What nursing diagnosis for physical effects?
Altered mental and temperature status, related to dehydration and infection, and manifested by afebrile temperature, dry skin, dark urine, & skin turgor.
short acting and able to reverse effects faster.
Nurse role in consent?
Witnessing their signature to consent to surgery.
Over weight, abdominal surgery?
Infection and dehissense, related to fat has less circualtion so heals at slower pace, and manifest by longer healing time.
Low patassium: Nursing action?
Document, then call and notify doctor.
Patient teaching to cough effectively after surgery?
Purpose of Assessment in PACU?
Watch for complication from surgery, big risk for cardiac and respitory complications.
- ABC's= A=Airway
Bleeding- Nursing Action?
Where to check for bleeding?
Pressure, report finding to doctor, and document.
Underneeth them, or behind them.
Rationale for semi-fowlers R/T respiratory?
Post surgery: Patient teaching?
Follow up, don't drive, don't sign any legal or important documents.
Define unintentional wound?
Jagged edges, hard to suture, and risk for infection.
Patient teaching: Prevent infection?
Wash hands and good wound hygine.
What are DRG's?
Diagnostic Related Groups= set amount of $ and how long you can stay.
Long-term Care Facilities?
Have to qualify and any age.
How can nurses shape health care reform?
Get involved and get politically active.
HIPAA: Mandated information to patient?
How information will be shared.
Discharge Planning rational?
Continuity of care, released to family, self-care, or long-term care setting.
Personal space: Signs of invasion?
Backing Away from you.
Nonjudgemental feeling for them, and can relate to them.
Helping relationship: Action during orientation Phase?
Introduce self, then address them, asking "whats your name?", and see what they would liked to be called if there is a preference.
Define autocratic leadership?
One man rules, a dictatorship.
Why give lasix and aldactone together?
They potensiate each other, and Balance Electrolites.
Patient requests medication:
No order- nursing action?
Call doctor and get order for one.
Examples of medications errors?
- Not doing 3 checks, and the 7 rights.
- 3 Checks: out (site), compare MAR, and back in or to patient.
- 7 Rights:Right drug, right dose, right patient, right time, right route, right reason, right documentation.
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