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36 Cards in this Set
- Front
- Back
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Correct explanation of catheter care |
Catheter care involves cleansing of the perineal area and around the catheter itself.Assessing the drainage system for leaks.Proper catheter care helps prevent skin breakdown in the area of a catheter |
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Know what is enema |
The installation of a solution into the rectum and sigmoid colon.Promotes defecation by stimulating peristalsis.The introduction of the fluid into the rectum and lower colon. |
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Explaining colostomy and ileostomy, ileostomy is |
A surgically created opening of the colon out onto the abdomen wall.Are procedures where a surgeon connects parts of the intestines to an opening in the abdomen where stool drains. |
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After foley cath has been removed, nurse should
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measure amount of urine in the patient’s first voiding.
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Nurse is educating bowel elimination, all are true except... FYI: this always get wrong, remember fluid intake 2000-3000 |
A balanced diet including high fiber foods, a daily fluid intake of 2000 mL to 3000 mL.Activity to promote muscle tone and peristalsis. |
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True about altered bowel elimination. SATA... 5 answers |
Constipation, obstruction, diarrhea, bowel incontinence and acute pain.Deficient knowledge regarding condition treatment program and self care.Disturbed body image, risk for impaired skin integrity, anxiety and ineffective coping. |
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During insertion of foley cath, pt grimaces as balloon inflated, what is the immediate action |
Stop inflation of balloon. Balloon is most likely still in urethra. Withdraw the solution from the balloon. Insert catheter an additional 0.5 to 1 inch (1.2 to 2.4 cm) and slowly attempt to inflate balloon again |
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SATA, statement pertains to ostomy care |
Cleanse the skin around stoma with warm water, pat dry.Measure stoma opening.Place toilet tissue over stoma.Apply protective skin barrier about 1/16 inch from stoma. Cleanse the skin around stoma with warm water, pat dry.Measure stoma opening.Place toilet tissue over stoma.Apply protective skin barrier about 1/16 inch from stoma. Cleanse the skin around stoma with warm water, pat dry.Measure stoma opening.Place toilet tissue over stoma.Apply protective skin barrier about 1/16 inch from stoma. Cleanse the skin around stoma with warm water, pat dry.Measure stoma opening.Place toilet tissue over stoma.Apply protective skin barrier about 1/16 inch from stoma. |
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Not true statement about hemorrhoid |
Internal hemorrhoids are painless. External are painful. |
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Standard technique of enema(687) |
Lubricate 4 inches()10cm)spread patients buttocks to exposed anusrotate tube; gently insert it 3 to 4 inches (7 to 10 cm)Instruct patient to breathe out slowly through mouth |
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Patient who is at risk for problems with urine elimination include those who have undergone surgical procedure of:
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Who have undergone surgical procedures of the bladder, the prostate, or the vaginaPatients with primary urologic problems, such as urethral stricture.Also those who are critically ill with multi system problems |
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12. The nurse would prefer this type of catheter for pt with enlarged prostate(662) |
Indwelling catheter with coude tip or Tiemann catheter |
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Presence of air in the intestinal tract is called (685) |
Flatulence |
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When doing urinary cath care, everything is being followed except.... remember it has to be closed (663) |
Except to irrigate the catheter, and then only with a specific order from the Provider |
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Providing instruction to UAP about cath care, appropriate institution is(662) |
The nurse of the facilities should instruct the UAP to measure amount of urine |
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When pt is observed with streaked of blood in the stool, priority nursing action is. |
Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool.Bleeding gastric ulcer would lead to black, tarry stools as the blood is digested.Colon polyps do not cause bleeding |
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Accurate characteristic of human urine |
color- pale yellow to deep amberodor- odorlessvolume -750 ml -2000 ml/ 24 hrpH 4.5 -8.0specific gravity 1.003- 1.032Osmolarity 40-1350m Osmol/kgurobilinogen 0.2 -1.0 mg/100 mlwhite blood cells 0-2 HPF (per high power field of microscope)leukocyte esterase - noneprotein - nonebilirubin - < 0.3mg/100 mlketones - noneNitrites -noneblood - noneglucose - none |
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Factor that doesn't contribute to the pt chronic constipation |
laxatives cathartics
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Read about accurate administration of enema?(694 |
consist of the slow installation of the correct volume of warm solution |
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Unusual findings after catheterization and need to be reported immediately Needs 4 answers |
No urine outputBladder discomfort despite catheter patency Leakage of urine from catheter Inability to insert catheter |
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. 3 answers simple nursing measures for pt having difficulty voiding |
Straight catheter Record fluid intake Urinary outputEncourage the patient to drink plenty of fluids to flush the urinary track. |
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Male pt needing catheter, one use of urinary cath
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Coude Catheter for male pt with enlarged prostate (pg |
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What is suprapubic catheter |
Catheter or tube is inserted through an incision or puncture made above the pubis.Inserted through abnormal wall above symphysis pubis into bladder. |
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Accurate characteristic of normal stool |
Color, odor, consistency, shape, density, abnormal components and fecal impaction |
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When should the nurse implement digital removal of feces |
Rectal examining by the primary health care provider is sometimes necessary to determine the nature of the problem. |
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Before digital fecal impaction, pt hx that the nurse should be alerted. Meaning what type of dx to be contraindication of digital fecal impaction |
Cardiac disease |
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27. The Nurse is instructing the patient in performing Kegel exercises. the patient should be instructed to contract the muscles he or she would use to stop the flow of urine. What is the proper technique for Performing kegel exercises. (695 question #19) |
Contract for 10 seconds and relax for 10 seconds |
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UTI is most common type of....... in health care
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Nosocomial Infection |
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Before removing urethral cath, this should be ordered to improve bladder tone
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Clam po unclamp |
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A male patient with urinary incontinence has been using an external(condom) catheter. The nurse is evaluating the patient’s technique of applying the device. which would indicate that the nurse should give the patient further instructions? |
#2) Spiraling the tape around the penis to secure the device |
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Teaching to include when using condom catheter. 3 answers |
Use a NEW CONDOM CATHETER/ reuse clean with soap and water once a weekWash hands with soap and water before and after doing cath careEmpty when it is ⅔ full Write down how much urine |
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32. The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complication?(question #25 from book pg 696) |
1)Fungal infection#2)infection#3) yeast infection#5)Skin breakdown around the stoma |
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. The nurse is caring for a patient with new ostomy. What is the best nursing strategy for encouraging patient self- care of an ostomy?(693 & # 21 from pg |
3) Encourage patient to watch the stoma care procedure, gradually encouraging participation |
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34.If Pt is suspected of having a fecal impaction, which type of enema would the nurse anticipate the health care provider to order?(685 question # 4 pg 694) |
3)Oil retention Enema |
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35. Female pt needing foley cath, what type of position will be the patient placed at?(665 |
Supine position with knees flexed and knees about 2 feet apart |
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clarify on #35, female pt with foley needs irrigation, what type of position you would placed the pt?(671) |
Supine position in bed |
