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131 Cards in this Set
- Front
- Back
keeping cath drainage bag in the dependent position prevents?
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urinary reflux
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A client underwent total knee replacement and was placed on patient-controlled analgesia (PCA). The client has been activating the drug button an average of 4 times per hour. The nurse has assisted the client on and off the bedpan 2 or 3 times an hour for the past 2 hours. Urine output was about 50 ml with each void. The nurse now begins to suspect:
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retention overflow
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A client is scheduled for an intravenous pyelogram (IVP). Before the test the most important assessment the nurse performs is asking about:
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allergy to shellfish because allergy to iodine is suggested
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Elimination changes that result from obstruction to the flow of urine in the urinary collecting system may cause which of the following?
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UTI, retention, renal damage
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The nurse is teaching a group of young (20- to 25-year-old) women how to prevent urinary tract infections (UTIs). Which of the following foods does the nurse recommend consuming to reduce the incidence of UTIs? (Select all that apply.)
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prunes,cranberry juice, whole grain bread acidifys the urine
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bodys specific protective response against foreign agents and organisms
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IMMUNITY
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Name 5 functions of the kidneys(homeostasis)
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1filters and regulates blood contents 2 concentrations of electrolytes 3 acidity of blood ph 4 excretes metabolic waste 5 endocrine function
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what is the acidity of blood
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7.35-7.45
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Filtration occurs when substances and fluids are filtered from the ------ into -------
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tufts of cappilaries into bowman's capsule
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secretion is
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when substances are secreted from the blood into the renal tubules
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substances and fluids are reabsorbed from the renal tubules back into the blood (Na K)
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reabsorbtion
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how much water is filtered at glomerus
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180 liters
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name 8 factors influencing urination
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muscle tone--psychological--disease--sociocultural--fluid balance--surgical procedures--medications--diagnostic exams
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dysuria
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painful urination
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polyuria
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large amounts of urine--2.5 L over 24 hours
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less than 400ml a day
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Oliguria
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the need to get up at night and urinate
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nocturia
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urine that contains pus
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pyuria
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lack of ability to urinate
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retention
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involuntary leakage of urine
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incontinence
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anything that increases intraabdominal pressure like coughing sneezing jumping
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stress incontinence
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bedwetting
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Enuresis
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urinary retention
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Retention of urine in bladder retention with overflow 2000 to 3000 cc’s BPH
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Older individuals para and quadriplegics
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urinary incontinence
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ileal loop
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isolated ileal segment with ureters implanted in posterior portion of segment with protruding stoma on abdomen
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ureteosstomy
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left and right ureters tied together or separate
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most normal for urination
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5 times a day
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physical assessment
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Skin and mucous membranes Hydration = turgor mucous membranes Kidneys -Flank pain auscultation for bruits
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protein in urine is what range and be fine
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0-8mg or 100ml and is seen in people with renal failure
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glucose bilirubin and keytones are normally in the urine
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false
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what is the range of normal specific gravity
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1.010-1.025
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diluted has a ----- specific gravity
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low
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joe is dehydrated and his specific gravity of urine is
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high
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ph of urine can be what range
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4.6-8.0 and the higher then there is UTI or standing
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RBC
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0-4 and increased is caculi cystitis or trauma
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WBC
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0-5 and increased is UTI or pyuria
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pink or red urine urine indicates
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hemoglobin breakdown RBCs gross blood
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old red blood cells in urine
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brown to black urine
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when doing urinary diagnostic exams
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NPO bowel cleansing meds I/O and characteristics of urine
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KUB Film
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A KUB is a plain frontal supine radiograph of the abdomen. It is often supplemented by an upright PA view of the chest (to rule out air under the diaphragm or thoracic etiologies presenting as abdominal complaints) and a standing view of the abdomen (to differentiate obstruction from ileus by examining gastrointestinal air/water levels).
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IVP
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radiological procedure used to visualize abnormalities of the urinary system including the kidneys
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retrograde pyelogram
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a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney. The flow of contrast (up from the bladder to the kidney) is opposite the usual flow of urine hence the retrograde name. Reasons for performing a retrograde pyelogram include identification of filling defects (e.g. stones or tumors) as an adjunct during the placement of ureteral stents or ureteroscopy or to delineate renal anatomy in preparation for surgery. Retrograde pyelography is generally done when an intravenous excretory study (IVP or contrast CT scan) cannot be done because of renal disease or allergy to intravenous contrast.Relative contraindications include the presence of infected urine
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name 5 different diagnoses for urinary problems
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incontinence risk for infection impaired urinary elimination toileting self care deficit
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name 4 things to promote urinary health to client
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1 education 2 promote normal micturition stimulation of reflex and encourage fluid intake 3 promote complete bladder emptying 4 to prevent infection hygiene and acidify urine
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Computed Tomography Scan
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detailed images of structures within selected plane..looks for tumors and obstructions. assess for shellfish allergy if with contrast test is ordered
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Cystogram
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voiding cystogram is a functional study where contrast "dye" is injected through a catheter into the bladder. Under x-ray the radiologist asks the patient to void (usually young children) and will watch the contrast exiting the body on the x-ray monitor. This examines the child's bladder and lower urinary tract. Typically looking for vesicoureteral reflux, involving urine backflow up into the kidneys.
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Renal Arteriogram
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visualizes the renal arteries to detect narrowing or occlusion. a catheter is placed in the femoral artery and introduced up to the level of the renal arteries. assess for shellfish allergy
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urge incontinence
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involuntary passage of urine after a strong sense of urgency to void
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stress incontinence
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involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contractions
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reflex incontinence
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loss of urine involuntary at intervals without sensation of urge to void. Spinal cord dysfunction
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overflow incontinence
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Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. Autonomic neuropathy from diabetes or other diseases (e.g Multiple sclerosis) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the detrusor muscle (allowing for urinary retention). Additionally, tumors and kidney stones can block the urethra. In men, benign prostatic hyperplasia (BPH) may also restrict the flow of urine. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. Also overflow incontinence in women can be from increased outlet resistance from advanced vaginal prolapse causing a "kink" in the urethra or after an anti-incontinence procedure which has overco
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functional incontinence
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loss of urine caused by factors outside urinary tract that interferes with the ability to respond in a socially appropriate way to the urge to void. sensory -cognitive-mobility issues
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name 3 nursing responsibilities associated with bowel elimination
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assessing bowel function- promoting normal bowel health- Intervening to manage alterations in bowel function
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name 3 functions of the intestine
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motility absorption defecation
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This aids in digestion and absorption and contracts and relaxes the smooth muscle alternating back and forth
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segmentation
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where are most fluids absorbed at
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large intestine
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where are most nutrients and electrolytes absorbed at
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small intestine
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what are the divisions of the large intestines
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ascending transverse descending sigmoid rectum and anus
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certain diseases cause conditions that prevent normal passage of feces through rectum so an artificial opening is made called what
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stoma in the abdominal wall
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Loop colostomy
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usually performed in emergency when they suspect closure of colostomy-temporary large stomas in the transverse colon-the loop has 2 openings through the one stoma -proximal end drains stool and distal drains mucous and external device is removed within 7-10 days
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end colostomy
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one stoma formed from the proximal end of the bowel with the distal portion removed or sewn-many people have these after correctal cancer--hartmans pouch
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double barrel colostomy
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bowel is surgically severed in a dbl barrel and the 2 ends are brought out onto the abdomen - 2 distinct stomas
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Ileoanal anastomosis
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this is used in clients who need to have a colectomy 4 treatment of ulcerative colitis or polps-colon is removed creates a pouch from end of the small intestine and attaches pouch to the anus
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kock continent ileostomy
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small intestine is used creating a spherical reservoir - pouch has a continent stoma and valve that is drained with catheter
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colostomy
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creates opening in abdomen for drainage of stool from large intestine
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colonoscopy
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an exam of the entire colon into the rectum-clear liquids the day before and bowel cleaner-light sedation and sometimes enemas until clear
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Flex sigmoidoscopy
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a flexible or rigid lighted tube examines the interior of the sigmoid colon and light sedation is required
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occult blood test
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also called guaiac test useful 4 screening 4 colon cancer-avoid red meat fish raw veggies asprin can be done at home or hospital ulcerative colitis can cause false positive
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when placing an enema in a patient
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lower container or clamp tubing if client complains of cramping or fluid escapes and slow it down
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when fitting a stoma
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the opening around the appliance should be no more than 1/16 larger than stoma
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ph on ng tube shoul be between
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1 - 4
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name 5 places an enteral feeding tube can be placed
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1 nasogatric 2 Esophogastomy 3 Gastrostomy 4 Jejunostomy 5 Nasoduedenal
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Using endoscopy
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a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through a stab wound made in the abdominal wall. A retention disk and bumper secure the tube
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A firm and painful abdomen during or after enema administration could indicate perforation of the rectum
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true take vitals and call doctor
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Intact skin barriers without evidence of leakage can remain in place for 3 to 5 days
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How often should an ostomy pouch be changed?
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A client is diagnosed with colorectal cancer. Which type of ostomy is the client most likely to have after surgery?
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Loop colostomies are usually performed during emergency surgeries. End colostomies are more common as a result of surgical treatment of colorectal cancer.
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stress incontinence and how it is repaired
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kegals-surgery-biofeedback-electrical stimulation-absorbent products
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explain clean catch
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The urinary tract naturally contains bacteria, which can contaminate a urine sample. The clean-catch method is used to prevent these bacteria from getting into the urine sample. The clean catch can be used for a routine urinalysis, a urine culture, or other urine tests that require pure urine for accurate results. Urinate in toilet in beginning of stream and then into cup remove container from cup without stopping flow after getting 1-2 oz.
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what are the early signs of UTI
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fever,chills,malise, nausea and vomiting
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does a cystoscope require sedation
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yes to anxiety and trauma to the patient
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Most important thing that can occur with diversions is
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skin breakdown
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protein in urine would indicate
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a UTI
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specific gravity measures
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concentration of particles in urine
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what is a condom catheter and what are the factors to be aware of
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non invasive and make sure to leave a 2.5-5 cm (1-2in) space btw tip of penis and end of cath, never use adhesive tape, make sure blood flow is not impaired
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What is a Nephrostomy
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urinary drainage directly from one or both kidneys and a tube is placed directly into renal pelvis
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what to be aware of in a patient that has diarrhea
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edit dehydration/loss of Potassium/skin breakdown
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How do you prepare for a colonostmy
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clear liquids day b4,bowel cleaner,light sedation also
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After Joe has had a colostomy what should his diet consist of
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low fiber diets like bread,noodles,rice,cream cheese,eggs,lean meats,poultry...avoid fruits and veggies
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Explain different color of stools and what it indicates
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clay=no bile black=upper gi bleeding or iron red=hemmroids or lower gi bleed
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what should you as the nurse do for the patient after abdominal surgery
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listen to bowel sounds if no peristalsis do not feed
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Joe has too much potassium in his body(KA) what should you as the nurse give him
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Give IV insulin with glucose which will move it to ECF to ICF/ monitor blood sugar/ IV calcium gluconate can be given if cardiac arrithymias (edit)
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How would you check to see if joes Ng tube is in the right place
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edit xray or look at ph of gastric juices in stomach and should be btw 1-4
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What is Hypertonic solution do
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osmolarity greater than body fluid/shifts fluid into blood plasma by moving fluid from tissue cells ICF-ECF
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You are the nurse and amy is constipated how will you treat this
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slowed peristalisis, fiber, mobility, fluids
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Agglutination is what
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clumping effect occurring when an antibody acts as a cross link between 2 antigens
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phagocytosis is a WBC
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cells that engulf destroy ingest foreign bodies or toxins
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WBCs or leukocytes participate in
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the natural and acquired immune responses
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a phagocytic cell is also referred to as
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nongranular leukocytes/monocyte
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The inflammatory response is elicited in response to
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tissue injury or invading organisms
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what happens when something becomes inflammed
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blood loss is lessened/ walling off invading organism / phagocytes are activated and scar tissue is formed/ regeneration of injured tissue
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physical and chemical barriers are facilitated by
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inflammatory response
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T cells are important for what
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producing a cellular immune response
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descendants of stem cells become what
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B and T lymphocytes
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Tcells move from the bone marrow to thymus where
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they mature into several kinds of cells with different functions
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In the proliferation stage t cells turn into ? and B cells do what
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T cells into cytotoxic killer and b cells produce and release antibodies
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first cells to be on site of infection
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neutrophils
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cellular response t cell includes
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transplant rejection-viral /fungal/parsite infections
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humoral response includes b cells
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bacterial and some viral/anaphylaxis/asthma/hay fever
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Tcells can become killer and do what
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attack antigen directly and get outside help
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Natural Immunity is what
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rapid immunity and is present at birth
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True
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natural immunity has a broad spectrum of defense against and resistance to infection
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natural immunity provides a nonspecific response
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to ANY foreign invader
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This is able to tell self from non self
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natural immunity
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Acquired Immunity is
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acquired in life but not at birth and usually develops as a result of prior exposure to antigen
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A Vaccine is what
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Acquired immuinty
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There are two kinds of lymphocytes
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the B lymphocytes and the T lymphocytes. Lymphocytes start out in the bone marrow and either stay there and mature into B cells or they leave for the thymus gland where they mature into T cells. B lymphocytes and T lymphocytes have separate jobs to do: B lymphocytes are like the body's military intelligence system seeking out their targets and sending defenses to lock onto them. T cells are like the soldiers destroying the invaders that the intelligence system has identified. Here's how it works.
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Once the B lymphocytes have produced antibodies
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these antibodies continue to exist in a person's body so that if the same antigen is presented to the immune system again the antibodies are already there to do their job. That's why if someone gets sick with a certain disease like chickenpox that person typically doesn't get sick from it again. This is also why we use immunizations to prevent getting certain diseases. The immunization introduces the body to the antigen in a way that doesn't make a person sick but it does allow the body to produce antibodies that will then protect that person from future attack by the germ or substance that produces that particular disease.
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Although antibodies can recognize an antigen and lock onto it
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they are not capable of destroying it without help. That is the job of the T cells. The T cells are part of the system that destroys antigens that have been tagged by antibodies or cells that have been infected or somehow changed. (There are actually T cells that are called "killer cells.") T cells are also involved in helping signal other cells (like phagocytes) to do their jobs.
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Antibodies can also neutralize toxins (poisonous or damaging substances) produced by different organisms. Lastly
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antibodies can activate a group of proteins called complement that are also part of the immune system. Complement assists in killing bacteria viruses or infected cells.
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Innate Immunity
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Everyone is born with innate (or natural) immunity a type of general protection that humans have. Many of the germs that affect other species don't harm us. For example the viruses that cause leukemia in cats or distemper in dogs don't affect humans. Innate immunity works both ways because some viruses that make humans ill — such as the virus that causes HIV/AIDS — don't make cats or dogs sick either.
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Innate immunity
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also includes the external barriers of the body like the skin and mucous membranes (like those that line the nose
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Passive Immunity
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Passive immunity is "borrowed" from another source and it lasts for a short time. For example antibodies in a mother's breast milk provide an infant with temporary immunity to diseases that the mother has been exposed to. This can help protect the infant against infection during the early years of childhood.Everyone's immune system is different. Some people never seem to get infections whereas others seem to be sick all the time. As people get older they usually become immune to more germs as the immune system comes into contact with more and more of them. That's why adults and teens tend to get fewer colds than kids — their bodies have learned to recognize and immediately attack many of the viruses that cause colds.
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Gamma globulin injections
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are usually given in an attempt to temporarily boost a patient's immunity against disease. Injections are most commonly used on patients who have been exposed to hepatitis A or measles
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antibodies are
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large proteins called immuloglobbins bc they are found in the globulin fraction of plasma proteins
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steroids cause
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immunsuppressive in Latent TB
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How do you identify a stoma
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edit color/moisture/bleeding
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Active immunity
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the immune defenses are developed by persons own body
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passive immunity
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is temporary from source outside of body that has gained immunity thru previous disease or immunization
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If your Potassium is high you can bring it down with Kayxelate via the oral or rectal route or you can give an IV of D5W with some insulin. For too little Potassium you augment their diet with Bananas, give them oral potassium or an IV with Potassium. JPM
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potassium
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active vs passive immunity
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Naturally acquired active immunity occurs when the person is exposed to a live pathogen, develops the disease, and becomes immune as a result of the primary immune response. Artificially acquired active immunity can be induced by a vaccine, a substance that contains the antigen. A vaccine stimulates a primary response against the antigen without causing symptoms of the disease (see vaccination).
Artificially acquired passive immunity is a short-term immunization by the injection of antibodies, such as gamma globulin, that are not produced by the recipient's cells. Naturally acquired passive immunity occurs during pregnancy, in which certain antibodies are passed from the maternal into the fetal bloodstream. Immunologic tolerance for foreign antigens can be induced experimentally by creating conditions of high-zone tolerance, i.e., by injecting large amounts of a foreign antigen into the host organism, or low-zone tolerance, i.e., injecting small amounts of foreign antigen over long periods of time. |
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Passive immunity response is immediate, but not long lasting. Because no time is taken for the production of sufficient level of antibodies,(as antibodies are being injected) and after the level of antibodies is reduced or they are used up-No more antibodies production is there.
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Most of the vaccines consist of non virulent, mutant strains of the poliovirus. The use of vaccines, which stimulate the production of antibodies in the body, and making a person immune against the disease or infection, is called active immunity. Active immunity response is not immediately available but it is long lasting.
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