Fundamentals exam 5
a 54 year old hospitalized patient with a diagnosis of congestive heart failure is normally quite alert and easygoing. now he seems unsure of the time of day, when you tell him it is early evening, he Becomes irritated with you what concern would you have
The patient may be developing hypoxia and further assessment is indicated
visceral pleura
The portion of the pleural membranes that covers the lungs
Which direction should you direct the tip of the enema tube as you inserted into the rectum to reduce the risk for perforation
Towards the patients umbilicus
Double Barrel Ostomy
Two distinct stomas present • One is proximal functioning stoma • Other is distal nonfunctioning stoma also known as mucous fistula
which of these patients is most at risk for developing a pressure injury
a 78 year old with a feeding tube who is nonambulatory and is incontinent of bowels and bladder
distention
being stretched out or inflated
hemorrhage
bleeding profusely
necrotic
dead tissue
contraction of which muscle causes the bladder to empty
detrusor
eschar
hard dry dead tissue that has a leathery appearance
incontinence
inability to control bladder and/or bowels
Factors Affecting Wound Healing
• Age • Lifestyle • Additional illness/wounds • Nutritional status • Oxygenation • Medications
which of the following best describes the importance of monitoring intake and output
it is a good way to assess overall fluid balance
your sister accidentally cut her finger while slicing tomatoes, this injury is an
laceration
Assessment Parameters for Bowel Elimination
o Frequency o Color o Amount o Consistency o Unusual shape o Unusual odor
your patient returned from surgery (laparoscopy) 4 hours ago and complains of being unable to empty her bladder, what step should you take next
palpate her bladder and if distended perform a bladder scan
Stage 1
• Intact skin with non- blanchable redness of a localized area usually over a bony prominence. (remains red for at least 15 -30 minutes after pressure is relieved) •The area may be firm, soft, or boggy and may be warmer as compared to the adjacent tissue. • Darker skinned individuals the skin may appear darker rather than red (look at surrounding skin) • May c/o burning or tingling
Incentive spirometer
A device used to encourage patients to take frequent deep breaths
Your patient has a blood pH of 7.48 and is on oxygen at 8L/min, which oxygen delivery device is best for this patient
A partial re- breathing mask
Tenesmus
A persistent desire to empty the bowel when no feces is present causing an effect of straining efforts
second intention
A pressure ulcer being packed with moist gauze
third intention
A traumatic wound first left open to drain and then sutured closed
Complications of Wound Healing
•Infection Staphylococcus aureus Escherichia coli Clostridia (gas gangrene) • wound dehiscence and evisceration •Hemorrhage: external, internal
Which of the following information regarding fiber would be appropriate for you to teach a patient
-A minimum of 25 to 30 g of fiber should be ingested daily -Many fruit and vegetable serve as good sources of dietary fiber
Patient is at risk for wound dehiscence As a result of nutritional issues and medical history which intervention should be included in the care plan
-Assess the patient to split the incision with a pillow when coughing -administer stool softeners and anti-nausea medicine promptly
Which is true of chemical regulation of respirations
-Chemo receptors are located in the carotid an aorta and the brain -The chemo receptors in the brain cause an increase in the rate and depth of respirations in response to changes in blood pH -If the carbon dioxide levels higher than normal in the blood the Blood becomes more acidic in the pH falls below 7.35
Medications for Diarrhea and Constipation
-Diarrhea o May coat the mucous membranes of the bowel, o Inhibit peristalsis o Treat the disease or infectious process causing the diarrhea o Probiotics -Constipation o May work by directly stimulating peristalsis, o Stool softners o Bulk adding to the stool (fiber)
When assess a patients skin you'll pay special attention to the color noting which of the following
-Erythema -pallor -bruising -jaundice
Which order for a patient with severe chronic obstructive pulmonary disease would you question
-Have oxygen continuously at 5L/min per nasal cannula
Do you listen to the patient's lungs in hear Adventitious Breath sounds bilaterally, you know a frequent productive cough of thick yellow sputum which other assessments will you quickly make
-Perform pulse oximetry to determine SaO2 -assess color of the lips, nail beds, and mucous membranes -Assess respiratory rate, character, and quality
Type of Catheters and Uses
-Straight (single lumen) :One-time drainage or sterile specimen -Indwelling (double lumen or Foley):Urine drainage for a specified amount of time -Three-way (triple lumen or Alcock): Transurethral resection -Coude -suprapubic -condom (Texas): male urinary; incontinence
Which of the following factors may prevent an individual from being able to consume an adequate amount of fiber in the diet
-The patient has poorly fitting dentures -The patient has edentia
Which of the following aspects of obtaining an arterial Blood gas sample are different from obtaining a venous blood sample
-The syringe has a small amount of heparin added to prevent clotting -The sample is taken from an artery not from a vein -After obtaining the sample the needle is inserted into the cork to prevent air from entering the syringe -The syringe is placed on ice after the sample is drawn
What is the purpose of the water seal in a chest tube drainage unit
-To reestablish the negative pressure in the pleural space -To prevent air from entering the pleural space through the chest tube
Several medications have G.I. side effects and may lead to diarrhea or constipation indicate which of the following medications would be most likely to cause constipation
-amphojel -meperidine -amoxicillin -Imodium A.D.
Before it is safe for you to delegate to the UAP administration of an enema to a patient it is necessary to
-ask if the UAP can identify steps to take to prevent perforation of intestinal wall -Ensure that the UAP knows what a vagal response is
which of the following signs and symptoms would indicate that your patient is beginning to become hypoxic
-becomes irritated when you try to help him turn in bed -respiratory rate change from 16-24 -thought he was at a hotel, but then knew he was at the hospital this morning -complaints of pain above his eyes
Arterial blood gases provide information about which values
-bicarbonate level -partial pressure of oxygen in the blood -PH of the blood -partial pressure of carbon dioxide in the blood
Which of the following food/drink items would be appropriate for the first 24 hours that an infant has diarrhea
-bottle of Pedialyte - bottle of room temperature chamomile tea
Urinary sepsis is a potential complications of any UTI because...?
-continuous membrane lines all the structures of the urinary system -bacteria from outside the urinary meatus can spread through the urethra to the bladder, then the ureters, and into the kidneys -the total volume of a persons blood flows through the kidneys each day to be filtered and this could allow bacteria to spread to the blood
open and closed wounds
-contusion; closed -abrasion;open -laceration; open -pressure injury; open
before you go in the room to change the dressing for your assigned patient who has stage 3 pressure injury infected with MRSA, your first priorities will be to
-determine supplies needed for the dressing change -obtain appropriate PPE for caring for a patient with MRSA -review sterile technique, to prevent contaminating the wound -review how to assess a stage 3 pressure injury
your patient with stage 3 pressure injury infected with MRSA is on contact precautions. which of the following PPE will you obtain when you enter his room
-gloves -gown
under what circumstances is it appropriate to use an indwelling catheter in a long term care setting
-if patient has a stage III or stage IV pressure ulcer -if the patient has terminal illness -if the patient has a severe impairment such that positioning and clothing changes are painful
your patient has been diagnosed with Pseudomonas, pneumonia and has thick secretions in his lungs you are most concerned about
-impaired oxygenation as a result of thick secretions in his alveoli
What will you teach your home health client regarding oxygen safety
-put up no smoking signs on the doors to the house -Keep the oxygen source in a different room away from any open flame heaters, fireplaces, or stoves -Use cotton and linen sheets and gowns not synthetics to decrease static electricity
You are assisting a patient who will be using a portable oxygen concentrator when discharged to go home and when she leaves her home in the future what will you teach a patient about the portable concentrator
-she will be able to take her concentrator on an airplane if she travels -The concentrator runs on batteries that lasts between two and four hours -The concentrator can be set on pulse flow or continuous flow -The setting when on pulse flow is not in liters per minute
your patient has stress incontinence which of the following statements represent recommended treatment for this problem
-suggest the patient wear incontinence pads in a comfortable style with adequate absorbency -tell the patient about kegel exercises
you have just inserted an indwelling catheter in a 56 year old male patient with urinary retention due to an enlarged prostate, you notice that the drainage bag is filling quickly, with 750ml of urine almost immediately draining into it, which of these actions will you take
-take no action because the patient is tolerating rapid bladder decompression without problems
which is true of UTIs in children
-they are very common, second only to respiratory infections -they may cause a toilet trained child to have accidents -they may cause poor feeding, vomiting, and diarrhea
which of the following assessments about a patients cough should be documented
-whether it is productive or nonproductive -color of sputum -approximate amount of sputum -consistency of sputum
Wound Documentation
•Anatomic location • Wound size (cm) • Wound base • Wound classification • Wound Edges/margins • exudate/odor • signs and symptoms of infection • Perri- wound skin condition •Pain
Peri-Wound skin
•Erythema •Induration •Maceration •Pigmentation •Edema
During your initial shift assessment one of your assigned patients for the day reports that he has not had a bowel movement since the day before yesterday you know that the maximum time that you should allow patient to go without having a bowel movement is
3 days
what is the minimum acceptable hourly urine output
30 ml
Complications of Enemas
1. Perforation of the colon 2. Vagal response: Symptoms: o Chest pain or heaviness, shortness of breath, dizziness, feeling faint, nausea -Signs: o Pallor, clamminess, pulse rate under 60 bpm
Oxygen concentrator
A device that removes some oxygen from room air and concentrates it for delivery of up to 4L/min requires electricity to work
Venturi mask
A mask that contains a plastic valve between the tubing from the oxygen source and the mask which allows a precise mix of room air and oxygen to equal a specific percentage of oxygen delivered to the patient
nebulizer
A medication delivery system containing an air compressor and a mouthpiece or mask
How will you know if your patient teaching about using the incentive Spirometer was effective
A patient will demonstrate the correct use of the spirometer and correctly answer questions about its purpose
Guaiac
A test done to determine the presence of hidden blood
Ankle-Brachial Index
ABI is a non-invasive vascular screening test to identify large vessel peripheral arterial disease by comparing systolic blood pressures in the ankle to the higher of the brachial systolic blood pressures, which is the best estimate of central systolic blood pressure.
When a lung collapses the condition is referred to as
Atelectasis
T-piece
Attaches to the flange of the tracheostomy oxygen flows from one side to the trachea exhaled air exits through the open end
Which of the following food/drink items would be appropriate after the first 24 hours that an adult has diarrhea
Bananas, piece of aged cheese, applesauce
hemothorax
Blood and drainage in the pleural space
Cyanosis
Bluish discoloration of the lips nose ears and nail beds as a result of decreased oxygen
Which description is most accurate regarding the mechanics of breathing
Breathing is involuntary and occurs because of the movement of thediaphragm and intercostal muscles
A patient from Africa has a positive reading after a TB skin test what is the significance of this
The patient may have a false positive result as a result of a malaria vaccine but needs follow-up testing
parietal pleura
The portion of a pleural membranes that lines the chest cavity
When you care for a patient with a tracheostomy it is important to first research
The purpose and type of tracheostomy the patient has, how to correctly section A tracheostomy
Which direction should you direct the tip of the enema tube as you inserted into the rectum to reduce the risk for perforation
Towards the umbilicus
An incision into the trachea held open with a tube to promote breathing is known as a
Tracheostomy
NURSING INTERVENTIONS FOR PATIENTS WITH IMPAIRED OXYGENATION
Turning Coughing Deep breathing :Incentive spirometry Nebulizer treatments Chest Physical Therapy Conservation of energy Supplemental oxygen
Uric acid:
Uric acid: results from breakdown of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA)
Your patient has been diagnosed with an enlarged prostate, he is at risk for which of the following
Urinary retention
Deep Tissue Pressure Injury
Usually begins over bony prominence • Differs from surrounding tissue • May form blood-filled blister or thin blister or may just be dark and discolored (purple, maroon, deep red) • The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to the Adjacent tissue
Alice Garber is a 78-year-old female patient who lives alone she was admitted to the hospital with malnutrition and anemia you are suspicious that she has a fecal impaction based on the fact that
She has been incontinent of small amounts of liquid stool several times today
You are administering an enema to a female patient who is constipated you notice the patient skin is pale and a little moist you take the pulse and obtain a rate of 44 BPM what do you suspect is occurring
She is having a vagal response
Shear VS. Pressure
Shear: are parallel, distort and break capillaries, result in tissue anoxia, cause wounds with undermining Pressure: are perpendicular to the bony prominence, exert most damage in areas with little subcutaneous tissue, cause deep tissue injury
Inflammation
Signs: •Heat • Swelling • Pain •redness •Redness and heat are consequences of increased blood flow= influx of immune defense cells to site of injury •Last approximately 1 to 5 days
A patient has signs of infection in his left shoulder incision arrhythmia, warm, and a small amount of purulent drainage, can you prepare to report this to the healthcare provider which information will you have ready when you call
Vital signs, appropriate laboratory results, patient's rating of incisional pain, description of the wound and drainage, signs of infection observed, name and dosage of antibiotics currently ordered if any
When reviewing the UA results of a patient with the diagnosis of dehydration which of the following would you expect to see
Specific gravity of 1.032
Factors that are known to cause diarrhea include
-Food allergies -Stress
Which is true of administering nebulizer treatments
-Medications must be mixed with Saline carefully to avoid overdosing -A healthcare providers order is required before a nebulizer treatment can be given
during the inflammatory process, which of the following physiological responses occur
-capillaries dilate, causing erythema and increased warmth at the site of injury -leukocytes move into the interstitial space and attack microorganisms -red blood cells deliver more oxygen and nutrients to promote healing -edema causes pressure on nerve endings, resulting in discomfort and pain
There are numerous things that you can do as a nurse that will make it easier for patient to maintain his or her normal pattern of bowel elimination while hospitalized which of the following actions would be helpful
-encourage adequate fluid intake each day -if activity is not restricted ambulate the patient in the hall at least three times per day
You are assisting a patient who has chronic lung disease with a shower the patient is very short of breath which of the following will you do to make the experience easier for the patient
-place a chair or bench in the shower so the patient can sit down while being washed -assist the patient into a terry cloth robe to absorb water rather than having him or her dry off with a towel
The patient is to receive a cleansing enema for relief of constipation which of the following factors must be assessed prior to administration of the enema
-type of solution to administer -date of last bowel movement -assessment of bowel sounds
how long can a urine specimen sit unrefrigerated before it is analyzed
1 hour
a colonized wound is one which
a high number of microorganisms are present without signs and symptoms of infection
You are administering an enema and have determined that the patient is having a vagal response what should your first action be
Stop enema and remove tube from rectum
hypoxemia
Oxygen level in the blood below normal range
NURSING CARE FOR PATIENTS WITH CHEST TUBES
Tape all connections securely and monitor for any air leaks Check lung sounds and respiratory status every 2 hours Assess for clots that might occlude the tubing What to do if chest tube comes out Check for crepitus Assess how the patient is tolerating Assess pain
The rhythmic wavelike contractions that begin in the esophagus and continue throughout the gastrointestinal tract to the rectum are called
Peristalsis
A patient must be section frequently through the nose which of these actions by the nurse would be most helpful
Placing a nasopharyngeal airway and suctioning through it
Non-breathing mask
Prevents the patient from rebreathing any exhaled air it escapes through a one-way valve that does not allow room air to enter only delivery device that can provide 100% oxygen one set at 15 L/min
defecation
Process of bowel elimination
Phase of healing during which granulation tissue forms in a wound is the
Reconstruction phase
Which of the following assessment data might indicate the patient is having difficulty excepting his or her new colostomy
Refuses to attempt care and tells you to just do it
CHEST TUBE DRAINAGE SYSTEM
Chamber One: For wet suction to pull drainage gently out of the pleural space Chamber two: for water seal to reestablish negative pressure in the pleural space Chamber three: collection chamber where blood and drainage are trapped and measured
CHEST TUBE PLACEMENT
Chest tubes are placed in the pleural space, between the visceral and parietal pleura to re- establish negative pressure Chest tubes that remove air are placed in the anterior superior surface of chest between 2nd and 4th intercostal space Chest tubes that remove blood and drainage are placed in the anterior inferior area of the chest between the 8th and 9th intercostal space
Which of these factors affect wound healing
Chronic illness, Medications, diabetes mellitus, age
Types of Urine Testing
Clean catch urine specimen Urinalysis Timed urinary collection Reagent testing Straining urine Common lab test: BUN, Creatinine, UA
Types of Enemas and Their Purposes
Cleansing enemas (tap water, NS, Soapsuds, Hypertonic NaPh, Milk and Molasses, HHH) o Relieve constipation or empty bowel for procedure Oil retention enemas o Soften hard stool of impaction Medicating enemas o Administer medication Return flow enema o Remove flatus
Normal Characteristics of Urine
Color: straw colored Clarity: clear Amount: 1,000 to 3,000 mL/day Odor: mild; slightly aromatic pH: 4.5 to 8.0 Specific gravity: 1.005 to 1.030 Should not have sediment, blood, or bacteria
The diversion created by bringing a portion of the large intestine or colon to the outside of the body through the abdominal wall is called the
Colostomy
tracheostomy collar
Delivers highly humidified oxygen through large tubing rest over the tracheostomy with an elastic band that goes around the neck
A patient returns from surgery with the left shoulder dressing a 3 inch diameter spot of red drainage is visible on the anterior portion of the dressing the healthcare provider does not want the dressing disturb for 24 hours what will you do
Draw a line on the dressing outlining the drainage with the date time and your initials
Urinary Conditions
Dysuria: painful or difficult urination Nocturia: waking at night to urinate Oliguria: urinary output less than 30 mL per hour Polyuria: urinary output greater than 3,000 mL per day Anuria: absence of urine Hematuria: blood in the urine
SIGNS AND SYMPTOMS OF HYPOXIA
Early: Agitation, anxiety, changes in level of consciousness, disorientation, headache, irritability, restlessness, tachypnea Late: Bradycardia, cardiac dysrhythmias, cyanosis, decreased respiratory rate (bradypnea), retractions
you have removed an indwelling catheter from a Post surgical patient which of the following would need to be reported to the healthcare provider
Eight hours after the catheter was removed the patient has not voided
Care of the Urinary Drainage Bag
Empty every 8 hours and document amount Do not touch drainage spout to any surface and wipe with alcohol before closing Always empty urine in a graduate to measure it Maintain bag below the level of the bladder Keep tubing free of kinks and coils Hang on bed; do not rest on floor
A patient with COPD is having difficulty eating what might you suggest to help her
Encourage the use of low carbohydrate and high protein and high calorie meal supplements
Initiating Bladder Training
Ensure adequate amount of fluids, 64 oz/day Avoid caffeinated beverages Drink more during a.m. and less in p.m. Offer fluids throughout the day; avoid large volume at one time Provide regular opportunities for toileting Mimic patients' normal voiding patterns
Which one of the following assessment findings makes it impossible to stage a pressure injury
Eschar
A patients J-P drain should be emptied
Every 8 hours When one-half to two-thirds full
Normal bowel elimination
FREQUENCY? INFANTS 3-6 BMs EACH DAY o CHILDREN 1-2 BMS EACH DAY o ADULTS 1-2 BMs EACH DAY NORMAL STOOLS: SOFT, FORMED, LIGHT YELLOW-BROWN TO DARK BROWN AND SLIGHTLY ODIFEROUS. o IF THE PT EATS SPINACH THEY CAN BE GREEN, BEETS TURN IT RED, IRON BLACK. o NEWBORNS MOVE FROM MECONIUM TO YELLOW SEEDY STOOL (If breast fed)
plural effusion
Fluid in the chest cavity
constipation
Hard formed stools that are difficult to pass
Another name for the Siphon enema is
Harris flush
A female patient is recovering from abdominal surgery two days ago her abdomen is distended and firm and she complains of moderate to severe cramping and abdominal discomfort as of yet she has been unable to pass much flatus rectally which type of enema would be most helpful to this patient
Harris flush enema
When you look at the arterial blood gas results on your patient you see that his pH is 7.32 what concerns do you have for this patient
He is in acidosis
Wound Healing Inflammatory Phase
Hemostasis: • Vasoconstriction • Platelet aggregation • Clot formation Phagocytosis: • inflammation increased transport of nutrients, oxygen andWBC • immune activation phagocytosis: removal of bacteria and debris
A postoperative patient who underwent an abdominal hysterectomy two days ago complains that she is becoming constipated this does not surprise you because
Her activity level has been less than normal because of the surgery, she has been receiving narcotic pain medication for postoperative pain
Which of the following statements made by patient with incontinence would indicate a need for further teaching
I can stop doing Kegel exercises when I no longer have a problem with leaking
you are teaching a home care patient about self catheterization, you know more teaching is needed when the patient states
I do not need gloves or any special precautions because i am in my own home
the nurse realizes that the patient with a shoulder incision needs more teaching when the patient says
I will take these antibiotics until the doctor removes the staples
What is the advantage of using a Yankauer section device or tonsil tip to section the patient's mouth
If the patient bites down the device will not be damaged and can still be used for suction
The diversion made by bringing the ileum to the outside of the body through the abdominal wall for elimination is called
Ileostomy
A patient with a tracheostomy who is not Connected to a ventilator begins to choke when drinking water what action will you take
Inflate the cuff if it is not fully inflated
A special type of medicated solution administer directly for the purpose of lowering a very high potassium level is known as
Kayexalate enema
Causes of Urinary Retention
Kidney stones Enlarged prostate gland Tumor Pregnant uterus Infection or scar tissue Nerve disorders Postoperative complications
Indicate the path of the flow of urine through the following structures by numbering them in order
Kidney, ureter, bladder, urethra, meatus
Hypoxia
Lack of oxygen taken to the tissues by the blood a result of hypoxia
Why might a patient with low oxygen saturation misinterpret stimuli
Lack of oxygen to the brain causes the inability to reason and use normal judgment
You are caring for a 67-year-old male who had a cerebral vascular accident three weeks ago, in addition he has developed a pressure injury on his right hip which of the following data that you collected will be useful in developing a care plan that will address as pressure ulcer
Last week he weighed 165.5 pounds and today he weighs 161.8 pounds, the pressure injury is at stage III, he is not able to set up in a chair for longer than 15 minutes at a time, he just likes cheese, beans, chicken and fish but love steak, eggs all kinds of nuts and peanut butter, he has been on a egg crate mattress while in the hospital
A patient who has chronic lung disease is stimulated to breathe because the chemo receptors detect
Low oxygen in the blood
For the lungs to expand when the chest wall expands it is important to
Maintain negative pressure in the pleural space
Partial re-breathing mask
Mask with bag attached that traps carbon dioxide for rebreathing to lower pH levels
Which Are accurate statements about a deep tissue pressure injury
May be caused by a medical device such as a splint, it is deep red maroon or purple colored and does not blanch, It may be in tact or non-intact skin, it is the result of prolonged pressure and or sheer force
Blood from higher in the digestive tract such as the stomach that has been partially digested and has a distinctive old blood odor and a black tarry appearance is known as
Melena
Melena:
black and tarry
Cystitis:
bladder infection
hematuria
blood in the urine, either visible or microscopic
occult blood
blood that is hidden or not visible to the naked eye
a patient has an injury on his arm where the skin has been scraped this injury is an
abrasion
anuria
absence of urine or minimal urine production
if a patient had a stage 3 pressure injury, you would expect to see which of the following on assessment.
an open area that extends through the epidermis , dermis, and subcutaneous tissue with possible undermining and tunneling
as you assess your patient with a dark skin tone, you notice that the color of her skin is ashen. what will you do next
assess the patients mucous membranes, palms, and soles of the feet for evidence of cyanosis
Piped-in oxygen
found in health care facilities with a wall outlet above the bed. Flow meter is inserted into the wall to access oxygen within the pipe
Flatus:
gas
new tissue that looks red and semi transparent that grows to fill in a wound is called
granulation tissue
Constipation:
hard stools; difficulty passing stools
a frail elderly patient with a hip fracture has to void before surgery which of the following is the best way to handle this
have the patient use a fracture pan
in addition to collecting all urine passed in a 24 hour period, one of the most important steps in obtaining a 24 hour urine sample is to
have the patient void, discard this urine, note the time, and then begin collecting
a patient with an open leg wound has the following laboratory results on his chart; WBC 15,350mm3 with an elevated percentage of neutrophils. what does this tell you about the patients wound
he most likely has an acute wound infection
o Occult blood
hidden blood in the stool
you are caring for a patient who is severely anemic and has atelectasis of the left lung, these conditions can easily lead to
hypoxia and hypoxemia
urinary tract infection (UTI)
caused by the presence of pathogens within the urinary tract
You are delegating the task of monitoring the output of an elderly male patient at risk for oliguria. He has an indwelling catheter in place. Which is the mpost appropriate direction for you to give to an unlicensed assistant?
check his output after 2 hours, if it is not above 60ml let me know immediately
how can you assess a patient for exertional dyspnea
compare the patients respiratory rate at rest with the respiratory rate at rest with the respiratory rate when the patient ambulates for even a short distance
which two tests are most important in assessing kidney function
creatinine and eGFR
if a patient had an order to discontinue a catheter the day after surgery under what circumstances might you consider delaying doing so until you talk with the physician
if the patients output is less than 30 ml/hr
urge incontinence
incontinence related to bladder spasms and contractions
functional incontinence
incontinence related to inability to get to the bathroom
stress incontinence
incontinence related to weak pelvic floor muscles
a tube that remains in the bladder, also known as a double lumen catheter or a foley catheter
indwelling catheter
you have been asked to explain internal and external respirations to another student. which explanations will you use
internal respirations occur when oxygen and carbon dioxide are exchanged between the bloodstream and the body cells external respiration occurs when oxygen and carbon dioxide are exchanged between the alveoli and the lung capillaries
you are assigned to care for a patient with an indwelling catheter, a 24 hour urine collection is ordered. how will you keep the urine from deteriorating and affecting the outcome of the test
keep the drainage bag in a basin containing ice, empty the drainage bag every 8 hours into the 24 hour collection container, which you are keeping in a refrigerator
order the path of urine through the urinary system
kidney ureter bladder urethra urinary meatus
Pyelonephritis:
kidney infection
renal calculi
kidney stones that can occur anywhere in the renal system from the kidney to the urethra
total incontinence
loss of urine with no warning
an elderly patient who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection because he
may not see well enough to notice changes in the wound that indicate infection
blood urea nitrogen (BUN)
measures a waste product normally eliminated from the body by the kidneys, elevated levels may reflect infection or some degree of kidney impairment
contraction of the diaphragm is initiated by the
medulla sending impulses to the phrenic nerve.
when making an assessment on a young child, you note retractions around the ribs and the sternum, which action will you take first
notify the physician immediately
Fecal Impaction
o Blockage of the movement of feces by a mass of very hard stool o Common cause is overuse of laxatives o Small amounts of diarrhea can indicate an impaction o If not relieved, obstruction or perforation can Occur. o During removal, watch for vagal stimulation.
Process of Digestion, Absorption, and Metabolism of Nutrients
o Bowel elimination occurs after nutrients are moved through the GI tract o In the stomach, enzymes break down the bolus of food, converting it to chyme (semi-liquid mass of partly digested food and digestive secretions.) o The chyme passes through the pyloric sphincter and into the small intestine (duodenum, jejunum, ileum), where the nutrients are absorbed o The remaining chyme passes through the ileocecal valve into the large intestine to be passed as stool - large intestine mostly absorbs water
Factors Affecting Bowel Elimination
o Change in activity level o Change in dietary intake Change in water source Change in fluid volume intake o Side effects of medication o Side effects of surgery o Pregnancy •High stress levels and emotional problems • laxative abuse • aging process • structural changes • food allergies •Nerve damage or impairment
Peristalsis
o Consists of rhythmic wavelike movements beginning in the esophagus and continuing to the rectum o Involves contraction of the circular and longitudinal muscles in the walls of the GI tract o Propels the bolus of food through the GI tract o Begins in the Os, or mouth, and ends in the anus with defecation
Nursing Interventions to Promote Bowel Function
o Increase physical activity o Ensure adequate fluid: up to 2,500 mL/day Increase fiber intake to 20 to 30 g/day (gradually!!) o Provide privacy o Position patient upright for elimination o Provide stimulants that "cue" bowel function at home, such as a cup of hot coffee before breakfast
Abnormal Characteristics of Stool
o Liquid, watery, unformed, hard, dry Balls, clumps, flat or ribbonlike, pencil-like o Bright red blood, black, coffee-ground appearance, pale, white, gray, or claylike o Presence of pus or mucus; floating on water o Presence of worms or eggs o Foul odor, bloody, or metallic smell
Diarrhea
o Loose or watery stools 3 or more times per day. o Watch for dehydration and fluid and electrolyte imbalances. o Contributing factors o Lactose intolerance o Medication side effects o Clostridium difficile o Anxiety and stress o Diverticulosis o Inflammatory processes o Food allergies
Contraindications to an Enema
o Rectal surgery o Severely bleeding hemorrhoids o Ulcerative colitis or Crohn's disease o Rectal fissure o Rectal cancer o Potential for excessive bleeding o Certain heart conditions, such as MI or unstable angina
Interventions for a Patient Exhibiting Vagal Response
o Stop the enema by clamping the tube o Remove tube from rectum o Place patient in supine position o Assess BP and pulse rate, skin color, and whether the patient is diaphoretic o Call for immediate assistance but do not leave the patient alone o lf pulse rate is below 60 bpm, place the patient in shock position (flat with feet elevated) o Apply oxygen if needed
Solutions Used in Cleansing Enemas
o Tap water o Normal saline o Soap suds (castile soap only) o Hypertonic sodium phosphate (Fleets) o Oil solutions o Medication enemas o Return flow (Harris flush)
dysuria
painful or difficult urination
a patients abdominal wound starts to separate, revealing the inner layers of muscle, this is called wound
dehiscense
while assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. what action will you take
document your findings and assess again in 2 hours
The proper name for the fecal material expelled from a new colostomy is
effluent
when a patient tries to lift a piano shortly after surgery, his abdominal incision separates, and his intestines protrude through it, this is called
evisceration
Defecation:
process of bowel elimination
you are caring for a patient with several risk factors for a pressure injury, which would you avoid when caring for this patient
pulling the sheets from beneath the patient so she does not have to turn frequently
erythema
redness of the skin
ischemia
reduced blood flow to tissues
debridement
remove by cutting
MRSA
resistant strain of staphylococcus aureus
Urea:
results from amino acid metabolism
the drainage in a patients Jackson-Pratt drain is red and appears bloody, this drainage is called
sanguineous
the drainage from a patients wound is pink, this drainage is described as
serosanguineous
the drainage on the dressing over a patients old IV site is clear and slightly yellow, this drainage is described
serous
Diarrhea:
several liquid stools per day
which emotional response do you think most people will experience when they need to ask for assistance with urinating
shame/embarrassment related to loss of autonomy
your patient has a glomerular filtration rate GFR of 45ml/min over a 3 month period, what does this tell you about her kidney function
she has chronic kidney disease
your patient has recently woken from a nap, she thinks its morning although it is 3pm she also thinks your her daughter in law, when you take her vital signs her pulse is 56 and irregular her respiratory rate is 28 and she is having difficulty taking a deep breath, her earlier vital signs were T 99.2, P 66, R 18, and BP 134/76, what concerns do you have about this patient
she may be hypoxic because her vital signs have changed and so has her orientation
is a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin
sinus tract
The mouth or opening of an ostomy is called the
stoma
steatorrhea
stool containing an abnormally high amount of undigested fat
Fecal impaction:
stool obstruction
a single tube with holes at the end that is used to empty the bladder or residual urine or to obtain a sterile urine specimen from the bladder is a
straight catheter
one important nursing intervention for patients with suspected renal calculi is to
strain the urine
when urine leaks out of the bladder as a result of increased abdominal pressure, it is referred to as
stress incontinence
Distention
stretching out
one quick and common way to get a lot of data about urine is by
testing the urine with a multiple pad reagent stick
Guaiac test:
tests for blood in the stool
you are a nurse and you are running behind schedule on a very busy workday, the UAP offers to change a patients abdominal dressing for you, she is a first semester nursing student, what is the most appropriate response
thanks, but could you help mr. wu walk in the hall instead? that way I can get that dressing changed>?
overflow incontinence
the bladder does not empty because of an obstruction
neuropathic incontinence
the brain does not receive a message that the bladder is full
a patients face and neck are swollen when you palpate the area, you feel crackling beneath your fingers, what could this be an indication of
the patient has air from the lungs in the subcutaneous tissue
dialysis
the process of using a machine to filter waste products and salts and to remove excess fluid from the blood
specific gravity
the result of comparing the weight of a substance with the weight of an equal amount of water
which of the following makes catherization difficult but represents normal anatomy in older women
the urinary meatus is located in the vaginal opening because of atrophy of perineal tissues
a patient comes to the clinic where you are working as a nurse, he had surgery 2 months ago and is very concerned. he asks you to feel the scar on his side. you feel hard ridge beneath the incision scar extending about 1 cm on either side of the scar. which response is most appropriate
this is a normal part of scar healing and strengthening it will eventually thin out and become less hard
a patient has a black, hard, leathery scab on his left heel, the stage of this injury is
unstageable
the kidneys filter waste products from cellular metabolism out of the blood and excrete it in the urine, which of the following are the three most important waste products to be filtered
urea, creatinine, and uric acid
used for urine to be eliminated by a an alternate route rather than traveling through the bladder
urinary diversion
polyuria
urinary output greater than 3000 mL/day
oliguria
urinary output less than 30mL/hr
the inability to empty the bladder at all or the inability to completely empty the bladder is called
urinary retention
void
urinate or micturate
residual urine
urine that remains in the bladder after the person voids
Full Thickness
• Involves total loss of skin layers (dermis and epidermis) Frequently involves loss of subcutaneous tissue, muscle and bone • Often not as painful as partial thickness wounds
Remodeling/Maturation Phase
• Longest phase of wound healing •3 weeks to 2 years or greater • Tensile strength increased • As scar lightens in color become stronger/less elastic •Maximum-80% of original strength
Stage 2
• Partial-thickness loss and exposed dermis presenting ulcer as a shallow open with a red/pink wound bed. • Subcutaneous tissue not visible • May also present as an intact or open ruptured serum filled blister • surrounding tissue may be red and warm to the touch This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration
nocturia
waking up at night to urinate
after discontinuing an indwelling urinary catheter, what should you assess for
whether the patient has voided within 8 hours
which of the following orders would you expect the health care provider to write after receiving laboratory results for the patient with elevated percentage of neutrophils
wound culture and sensitivity
purulent
wound drainage containing pus
pressure injury
wound resulting from pressure or friction
sometimes patients are not aware that they retain urine if the residual urine volume is less than 300 ml and does not feel uncomfortable to the patient, is there any reason to try to correct the problem
yes because residual urine can lead to urinary tract infections
Arterial Disease
• Currently, there is no clinical evidence to indicate safe levels of compression when arterial impairment exists. • An ABI of<9_is considered lower extremity arterial disease. • An ABI should be performed prior to compression.
You are calling a healthcare provider to report a possible wound infection what information will you include in your report
Most recent vital signs, amount and type of wound drainage, observed signs of infection, patient's rating of his or her pain, laboratory results
Why is a patient at risk for pneumonia if he or she is unable to get out of bed
Mucus pulls in the lungs providing a favorable environment for bacterial growth
Residual bacteria that live in the intestinal tract and whose purpose is to prevent infection and maintain health are called
Normal flora
Which of the following types of enemas would be safe to administer to infants and patients with heart failure
Normal saline enema
The order structures that air passes through as it enters the respiratory system
Nostrils, pharynx, trachea, right or left bronchus, bronchioles, alveoli
The healthcare provider ask for a stat pulse oximetry Reading on a patient wearing dark nail polish what action will you take first
Obtain fingernail polish remover and remove the polish from one hour then attach the pulse oximeter to that finger
Risk Factors for Pressure Injuries
• Elderly • Emaciated or malnourished • Incontinent • Immobility Impaired circulation or chronic metabolic conditions
Signs & Symptoms of Infection in Chronic Wounds
• Erythema • Induration • Warmth around the wound • Pain or tenderness • Poor granulation tissue: dull, fragile • Purulent or increased wound exudate
Reconstruction/Proliferation Phase
• Fibroblasts form collagen > scar tissue strengthens the wound • Capillaries form new networks •Granulation: red and semitransparent tissue • Epithelialization-migration of epithelial cells toward each other • Contraction: shrinkage of wound begins • Lasts about 21 days
Healing classifications
• First Intention- surgical closure; edges are approximate • Secondary Intention- wounds left open and allowed to heal by scar formation • Third intention-managed with delayed closure; left open for 3-4 days, then closed by primary intention. Also called delayed primary closure
Undressing Wounds
• First, gather supplies-including saline, syringe (10- 60ml), angiocath, 4 x 4s, pad/towel • Assess patient for pain and need for medication • Position patient comfortably to remove dressing(s) • Keep old dressings to show provider exudate amount or other questionable drainage
Stage 4
• Full-Thickness tissue loss to muscle, fascia, tendon, joint capsule, and sometimes bone. • Often includes undermining and tunneling. • Infection can involve deeper tissues such as bone •Depth varies by anatomical location areas with no subcutaneous fat may be shallow areas with significant adiposity can be deep
Unstageable
• Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. • until enough slough and or eschar is removed to expose the base of the wound the true depth, and therefore stage, cannot be determined
Stage 3
• Full-thickness tissue loss. AKA Epidermis, dermis, and subcutaneous tissue involved. • May include undermining and tunneling and rolled wound edges. • depth varies by anatomical location, areas with no subcutaneous fat may be shallow, areas with significant adiposity can be deep. bone tendon muscle not involved
Compression
• Gold standard for venous ulcers • Constricts the dilated veins and assists the flow of blood back to the heart • Decreases edema allowing ulcers to heal through improved microcirculation • Serves as a stable support for leg muscles and improves the function of the calf muscle pump
Moist Wound Healing
• Studies have shown that a moist wound resurfaces consistently more rapidly than wounds which are allowed to dry out. • The basic concept behind moist wound healing is that the presence of exudates in a wound will provide an environment that stimulates healing. Exudate contains various components, including: lysosomal enzymes, WBC's, lymphokines and growth factors.
Gauze Dressings
• description - inexpensive, user dependent • indications - to fill deep defects, to maintain moisture and absorb exudate, may be soaked with antibiotic solution • considerations - pack lightly, may cause sürrounding wound maceration, may traumatize wound if allowed to dry.
Contact Layer Dressings (Greasy gauzes, N-terface)
• description- nonadherent, prevents trauma and permits exudate to "pass through" pores of dressing for absorption by a secondary dressing, inexpensive • indications superficial wounds with minimal to moderate exudate • contraindications,- if goal is to "clean up wound
Indications for Adults GI Stomas
•Cancerous tumor •Infarcted area of the bowel. •Crohn's Disease •Ruptured diverticulum •Ulcerative Colitis •Traumatic abdominal injury •Bowel perforation
Partial Thickness
•Classified by depth of wound •Involves the dermis, epidermis or both •Presents as superficial or as a shallow crater or abrasion • Usually painful
Mucous Fistula
•End stoma is exteriorized from small or large intestine •Then a second end stoma or mucous fistula is exteriorized from the functioning opening to the distal intestine suture line, or elsewhere on the abdomen •The MF may be located close to the proximal stoma, in the abdominal •Discharge is mucous or clear fluid
Dressing a wound
•Maintain moist wound healing environment • Consider length between dressing changes •Who will be changing the dressings? • Consider amount of exudate • Is compressions a factor? •Sterile vs Non-sterile • Environment/Facility
Cleansing Wounds
•Once dressing is completely removed, wounds should be cleansed with normal saline. • Measuring and documentation should be done after cleansing the wound •It is common for a wound to have an odor upon removing dressing. Do not document the odor until the wound is cleansed and it remains
End Of Stoma
•Proximal functioning end of a surgically divided structure exteriorized through an opening in the abdominal wall •Everted •Sutured to the skin •Stoma with a single opening •Temporary or Permanent •End colostomy, end ileostomy
Frank blood:
Abnormal...bright red blood in the stool; may be caused by hemorrhoids, intestinal bleeding, or hemorrhage
Steatorrhea:
Abnormal: stool containing abnormal amount of undigested fat, indicating malabsorption disorder ("fluffy and floats")
Hydrocolloids (duodenum, confers)
Absorbs maintains moisture insulates protects from secondary infection non-permeable indications for superficial burns with minimal to moderate drainage contraindications infected burns
It is common for patients who are taking antibiotics to develop diarrhea as a result of the loss of normal flora from the intestines which of the following interventions would be helpful for these patients
Add yogurt to the daily diet, Take lactobacillus acidophilus or other probiotics
EFFECTS OF CHRONIC LUNG DISEASE ON RESPIRATIONS
Air is trapped in the alveoli for long periods of time This raises the blood's level of carbon dioxide and lowers the oxygen level Body gradually acclimates to the higher carbon dioxide level High carbon dioxide level no longer stimulates respirations
CAUSES OF HYPOXIA AND IMPAIRED HΥΡΟΧΕΜΙΑ
Airway obstruction Anemia Atelectasis Chronic Lung Disease Decreased cardiac output High altitude Hypoventilation Poor peripheral circulation Pulmonary embolus
First intention
And appendectomy incision sutured closed
Characteristics of a new stoma
Appearance of newly created stoma differs with the type of tissue used in stoma creations • Large or small bowel • Stoma will have dark red, beefy appearance Perhaps with visible sutures at the skin and stoma interface Stomas from ureter or bladder appear pale pink Stomas are Moist Dark brown to black, ischemia should be suspected
Your patient has a large abdominal wound with copious drainage and many layers of gauze four by fours in the dressing, Patient develops a skin reaction to the tape due to frequent dressing changes but might you recommend for this patient
Ask the charge nurse about using Montgomery straps are in abdominal binder instead of tape
How can you evaluate the effectiveness of suctioning a patient's tracheostomy
Ask the patient if he or she can breathe more easily after suctioning Listen to see if the patient is breathing easily without rattling or gurgling
You are initiating a 24 hour urine specimen collection for patient as ordered by her healthcare provider which of the following will you do first
Ask the patient to void and then discard the urine
What would be the first assessment you would make of the patient to whom you were administering an enema said she was feeling lightheaded and faint
Assess pulse rate
You are caring for a patient who has lung disease yesterday the patient was pleasant and cooperative today the patient is irritable restless and a little confused she is also complaining of a headache what concerns you the most about the situation
All of the symptoms concerning because they could all be signs of early hypoxia
urge incontinence
Also known as overactive bladder, this type of incontinence is an inability to keep urine in the bladder long enough to get to the restroom
Which of the following would be the most accurate statement about digestion and elimination
An infant may have up to six bowel movements daily
24-Hour Urine Collection
Ask patient to void and discard first urine Note exact time urine is voided and discarded Post signs on door stating 24-hour urine is in progress Collect eyery drop voided during next 24 hours and measure in calibrated container kept on ice. If Foley is in place put collection bag in a container of ice. Exactly 24 hours later, have patient void one more time and add to collection Take specimen to the lab for testing
Which of the following interventions would you rate as the most important for care of his pressure injury
Change the wet to damp dressing on his right hip wound QID using sterile technique
In the G.I. tract a food bolus is converted into a semi liquid mass of partly digested food and digestive secretions known as
Chyme
Most water is absorbed in which portion of the gastrointestinal tract
Colon
Dyspnea
Difficulty moving air in and out of the lungs
Symptoms of UTI
Dysuria Urinary frequency Urgency Nocturia Low abdominal pain Incontinence Fever, chills, malaise, nausea, vomiting, and flank pain with pyelonephritis
Incentive spirometry is used to
Help prevent pneumonia and atelectasis
Dr. Rucker has ordered that The patient be tested for hidden blood you know to complete the laboratory requisition for
Guaiac test Hemoccult test
Laboratory Tests to Determine the Cause of Bowel Alterations
Guaiac test (occult blood test) o Tests for presence of blood in the stool Culture and sensitivity (C&S) o Identifies microorganisms infecting the stool and the antibiotics that will kill the microorganisms Ova and parasite test (0&P) o Tests for presence of parasitic worms and their eggs Stool specimen collection techniques
You are caring for a patient who has an asthma attack he is having difficulty breathing and is very anxious which would be the most helpful for you to say at this point
I won't leave you like this breathe with me in out in out that's good
liquid oxygen
Oxygen that is kept cold in a large barrel shaped container
Treatment of UTI
Increased fluid intake Antibiotics Urinary analgesics Pyelonephritis: hospitalization if IV antibiotics are needed Cranberry juice or tablets
Which of the following may decrease the incidence of UTI
Increasing fluid intake, voiding after intercourse, frequent voiding
Wounds heal in this order
Inflammatory phase, reconstruction phase, maturation phase
Which of the following factors is most likely to result in diarrhea
Loss of intestinal normal flora
The purpose of inserting chest tubes is to
Reestablish negative pressure within the pleural space
Which respiratory diagnostic test measures the amount of air that can be exhaled with force
Peak flow
When a hole allows air to enter the pleural space the condition is called a
Pneumothorax
You observe pink drainage from a patient's wound you would describe this as
Serosanguineous
diarrhea
Several liquid or watery stools per day
Which of the following descriptions of feces would not be normal
Several small hard pellet like brown pieces of feces
A healthy stoma should be
Shiny and moist, and a pinkish red color.
Commonly administered to relieve a patient of excessive intestinal gas is the
Siphon enema
A life-threatening situation occurs when the air is trapped in the pleural space surrounding the lungs causing pressure on the lungs heart and major blood vessels this is known as
Tension pneumothorax
incontinence
The lack of voluntary control of elimination of urine or stool
Which of the following signs and symptoms may be an indication of vagal stimulation during the digital removal of an impaction
Oil retention enema
Why do patients with chronic lung disease have difficulty eating and bathing
They must use the same muscles for breathing as they use to eat and bathe making it difficult to do both
all of the following are found during your assessment of a surgical wound, which would concern you the most
- the 2 cm margin around the wound is red, warm and swollen - the patient complains of increasing pain in the incisional area compared to yesterday
While assisting a patient who has a bowel movement of the bedpan you observe there is a large amount of bright red blood in the semi liquid feces you can even smell the blood immediately report to the physician that the patient has had
A bowel movement with Frank blood
External respiration
Occurs between The oxygen-poor the alveoli and via capillaries
endotracheal tube
A firm but flexible tube that is inserted through the nose or mouth to provide air to the lungs
flatus
A gas produced when intestinal bacteria interact with chyme
Creatinine:
Creatinine: the waste product of muscle metabolism
Occurs when the air in the subcutaneous tissues it feels like crispy rice cereal being crushed beneath the patient's skin
Crepitus
The blockage of the movement of contents through the intestines by a bulk of a very hard stool is known as
Impaction
Internal respiration
Occurs between the bloodstream and body cells
Assisting Patients With Toileting
Offer opportunity to use bathroom/bedpan upon awakening, before and after meals and at bedtime Allow male patients to void standing up if not contraindicated Use a fracture pan for patients with hip or back surgeries Provide privacy and avoid rushing Offer hand hygiene after toileting
A patient has had emergency surgery because of a bowel obstruction the wound becomes infected with E. coli this likely occur because
These bacteria are present in the bowel and with emergency surgery there is no time to perform special bowel preparations
