Nursing Theory Exam 1

Which of the following is an advantage of using a condom catheter for a male patient who has frequent episodes of urinary incontinence?

it collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

mass peristalsis occurs __ to __ times in 24 hours

1-4

sphincter control begins @ __ y/o

2

How long do you auscultate the abdomen

5 minutes

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which of the following diets?

A diet lacking in fruits and veggies

Which of the following accurately describes a guideline when inserting an indwelling catheter?

Avoid irrigation unless needed to relieve an obstruction

A nurse applies an aquathermia pad on the back of a patient with arthritis. What is the expected action that will occur with this application of heat?

Dilated peripheral blood vessels

Phases of wound healing (not stages)

Hemostasis: (immediately) Inflammatory: bring nutrients & WBC to site (3-6 days after) Proliferation: 3-24 days: deeper/ worse, scar tissue comes in, contract wound closed Maturation: takes up to a year- hard scar

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. Arrange the following steps in the correct order

Open sterile catheterization tray using sterile technique. Don sterile gloves. Open all sterile supplies. Clean each labial fold, then the area directly over the meatus. Slowly insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine.

Type of healing: heals rapidly, low risk of infection (cuts, nicks). Little to no tissue loss

Primary Healing

A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

Primary Intention

Type of healing that has some tissue loss and edges separated. Minimal scarring, longer healing, increased risk of infection

Secondary Healing

A pressure ulcer in which you can see the muscle/bone

Stage 4

A nurse assessing the access site of a hemodialysis catheter cannot palpate a thrill or hear a bruit. What is the most likely cause of this emergency situation?

The access may be clotting off.

Montgomery straps allow the nurse to change a dressing without the use of tape.

True

Use of an indwelling urinary catheter leads to the loss of bladder tone. (T/F)

True

laxative foods

caffeine, chocolate, nuts, prunes, high-fat, coffee

to feel for a full bladder, where do you palpate?

above symphis pubis

When something is torn off

avulsion

black necrosis v yellow necrosis

black=eschar yellow=slough

How do some medications affect would healing

blood thinner lower immune system decrease appetite/ thirst allergies

When educating a breast-feeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be

bright yellow

What should you put on the sterile solution label when you open it:

date and label

separation of a wound

dehiscence

Which of the following symptoms are known side effects of antibiotics?

diarrhea

During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify?

perceived constipation

3 types of healing

primary secondary tertiary

QSEN stands for

quality and safety education for nurses

Pressure ulcer stage: redness, discolor, blanchable no opening yet

stage 1

a pressure ulcer that lost 1st layer of skin (broken blister look)

stage 2

Type of healing: deep, widely separated. Long healing time, extensive drainage, debris, and scarring

tertiary

functions of large intestine

water absorption forms feces expels feces manufactures some vitamins

Root cause analysis

when death/injury occur: contact every person on case and figure out the cause: how to prevent it from happening again

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

adequate hydration/ nutrition for would healing

2-3L fluid/day 1500 cals

A nurse is caring for an elderly client at his home. The client has had a condom catheter applied. Which of the following describes a condom catheter?

A flexible sheath that is rolled around the penis

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record?

A separation of skin and tissue in which the edges are torn and irregular

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which of the following nursing diagnoses?

Bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the client to follow?

Drink two glasses of water before and after sexual intercourse

Ostomy irrigation

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?

Increased output of dilute urine

6 core competencies

Patient Centered Care Teamwork/Collab Evidence Based Practice Quality improvement Safety Informatics

A _____ drain typically exits a patient's skin through a stab wound created by the surgeon.

Penrose Drain

What is the micturition reflex?

The act of bladder contraction and perceived need to void

Which of the following factors is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation

A woman complains of bladder urgency. It is most important to assess

caffeine intake

A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following?

dysuria

How often should a fecal incontinence pouch be removed to check for signs of skin breakdown?

every 72 hours

dehiscence, but worse where you can see organs

evisceration

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

hydrocolloid dressings

A client's last bowel movement was four days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the patient in anticipation of administering a cleansing enema?

left side lying

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?

lubricates and softens stool

over hydration of a would

maceration

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a

neurogenic bladder

A pressure ulcer that has passed the subcutaneous tissue, don't see muscle or bone

stage 3