Chapter 20 21 22 23 24 25 26 27 28 29
urinary incontinence
Is treated with a catheter
bowel elimination
It is the excretion of wastes from the gi system
A person has an indwelling catheter. Which is not correct?
Keep the drainage bag above the level of the bladder
Mrs rose has a picc line in her right arm you need to check her blood pressure how should you proceed
Measure blood pressure in right arm
A person has an indwelling catheter you are going to turn the person from left side to the right side what should you do with the drainage bag
Move it to the right side
The risk of regurgitation is the greatest with
NG and gastrostomy tubes
comfort measures
Oral hygiene every two hours Lubricant for lips every two hours Mouth rinses every two hours Clean nose every 4 to 8 hours Secure tube to the nose
preventing aspiration
Position in Fowler or semi Fowler position before feeding Maintain the position 1 to 2 hours after feeding Avoid left lying position
Complications from bed rest
Pressure ulcers Constipation Fecal impaction Uti Kidney stones Blood clots Pneumonia
The purpose of bedrest is to
Reduce pain and promote healing
A person has an NG tube. The care plan includes the following measures to prevent nasal irritation. Which measure should you question?
Remove the tube every 4 hours
Which is not a rule for normal elimination?
Stay with the person who uses the bedpan
A person has an indwelling catheter. Which is not correct? 2
Tape any leaks at the connection site
A nurse asks you to give a tube feeding what procedure is not in your job description
Tell the director of nursing
Which does not promote comfort and safety for bowel elimination
Telling the person you will return very soon
Peristalsis
The alternating contraction and relaxation of intestinal muscles
Contracture
The lack of joint mobility caused by abnormal shortening of a muscle
These statements are about enemas which is false
The solution should be cool
Which is not a cause of functional incontinence
UTI
An ostomy pouch is usually emptied
When stools are present
syncope
a brief loss of consciousness; fainting
Colostomy
a surgically created opening between the colon and abdominal wall
ileostomy
a surgically created opening between the ileum and the abdominal wall
orthostatic hypotension
abnormally low blood pressure when the person suddenly stands up; postural hypotension
ADL
activities of daily living
When applying an incontinence product what part should you place in the persons perineal area
center
After a person uses a commode, you should
clean and disinfect the container, seat, and commode parts
ROM
range of motion
Formula for a tube feeding is given
room temperature
overflow incontinence
small amounts of urine leak from a full bladder
Sse
soap suds enema
Mr Cooper has a condom catheter. You apply elastic tape
spiral fashion
These statements are about ostomies which is false
stools are liquid
Twe
tap water enema
You note that an IV bag is almost empty. What should you do?
tell the nurse
You note bleeding from an IV insertion site. Which action is correct?
tell the nurse at once
transient incontinence
temporary or occasional incontinence that is reversed when the cause is treated
mixed incontinence
the combination of stress incontinence and urge incontinence
atrophy
the decrease in size or the wasting away of tissue
Calorie
the fuel or energy value of food
Deconditioning is
the loss of muscle strength from inactivity
urge incontinence
the loss of urine in response to a sudden, urgent need to void; the person cannot get to a toilet in time
functional incontinence
the person has bladder control but cannot use the toilet in time
Nutrition
the process involved in the ingestion, digestion, absorption, and use of foods and fluids by the body
Protein is needed for
tissue growth and repair
After using the urinal, the man should
to use call light
Tpn
total parenteral nutrition
internal rotation
turning the joint inward
reflex incontinence
urine is lost at predictable intervals when the bladder is full
stress incontinence
when urine leaks during exercise and certain movements that cause pressure on the bladder
Factors affecting bowel elimination
• privacy • habits • diet • fluids • exercise • medication • disability • aging
Drainage bags are emptied and urine is measured:
At the end of every shift When changing from a leg bag to a drainage bag When changing from a drainage bag to a leg bag When the bag is becoming full
I&o
intake and output
Bowel training is aimed at
Bowel control and regular elimination
aspiration
Breathing fluid, food, vomitus, or an object into the lungs
A person is receiving TPN the person complains of chest pain and difficulty breathing what should you do
Call for the nurse
Proper use of cane
Cane is held on strong side
Urinary incontinence
involuntary leakage of urine
A person is receiving TPN you know that Tpn
involves a nutrient solution
Hyperextension
Excessive straightening of a body part
Continuous tube feeding are given with a
Feeding pump
Which of the following is incorrect when performing rom
Force the joint beyond its present ROM
Which position prevent regurgitation after a tube feeding
Fowler semi Fowler
For a tube feeding, the person is positioned in
Fowler's or semi-Fowler's position
The person using a standard bedpan is in the
Fowler's position
Hipaa
Health Insurance Portability and Accountability Act
In adults, the enema tube is inserted
2-4 inches
The oil retention enema is retained for at least
30-60 minutes
On a 2000 calorie a day diet what is the amount of protein foods needed by an adult man
5 1/2 to 6 1/2 oz
indwelling catheter
A catheter left in the bladder so urine drains constantly into a drainage bag; retention or Foley catheter
Jejunostomy tube
A feeding tube inserted into a surgically created opening in the jejunum of the small intestine
nasogastric tube
A feeding tube that is inserted into the nose and goes to the stomach.
Nutrient
A substance that is ingested, digested, absorbed, and used by the body
Catheter
A tube used to drain or inject fluid through a body opening
Which is a peripheral iv site
A vein on the back of the hand
Which is true about the use of walkers
A walker gives more support than a cane
Dehydration
An abnormally low amount of water in the body.
The nurse checks feeding tube placement to prevent
aspiration
The IV flow rate is
b. The number of gtt/min
A person is taught to ignore the urge to void. This type of bladder training is called
bladder retraining
dysphagia
difficulty swallowing
The prolonged retention and buildup of feces in the rectum is called
fecal impaction
which helps prevent plantar flexion
foot board
When giving catheter care, you clean the catheter
from the meatus down the catheter about 4 inches
The goal of bladder training is to
gain control of urination
The process of giving a tube feeding is called
gavage
A person with a feeding tube is NPO. You should do the following except
give the person hard candy or gum
intravenous therapy
giving fluids through a needle or catheter inserted into a vein
enteral nutrition
giving nutrients into the gastro-intestinal tract through a feeding tube
parenteral nutrition
giving nutrients through a catheter inserted into a vein
enteral nutrition
is given into the GI tract
Which foods provide the most protein?
meats and fish
Mg
milligram
Ml
milliliter
Abduction
moving a body part away from the midline of the body
Adduction
moving a body part toward the midline of the body
Ng
nasogastric
Npo
nothing by mouth
Which is not used for a cleansing enema
oil
PEG
percutaneous endoscopic gastrostomy