week 4
A Coudé catheter is often used when a client has
an enlarged prostate
A nurse caring for a client with chronic diarrhea expects to find increased:
pulse rate
Which step is correct when collecting a urine specimen for culture and sensitivity from a client with an indwelling catheter?
collect urine from cathare’s special part
A nurse is assessing a client with a new ileostomy. Which finding would indicate a healthy stoma?
Pinkish to cherry red color of the stoma.
___ intestinal obstructions result from pressure on the intestinal walls. It is caused by various conditions, including tumors, adhesions, stenosis, and diverticulum.
mechanical
You are teaching an older adult client who reports constipation. Increased ___ diet is advised such as fresh fruits, raw vegatables, and whole-grain carbohydrates.
fiber
A nurse is monitoring the urinary output of a client. A 3000 milliliters of 24-hour urinary output total indicates _.
polyuria
What is the term used to describe black or tarry stools with a foul smell that are a sign of bleeding in the upper digestive tract?
méléna
A nursing student asked a nurse about indications for urinary catheterization. Which of following indications should the nurse include?
open perineal wound
A client who underwent surgery is experiencing decreased urine output postoperatively. Which nursing interventions should the nurse consider?
Use bladder scanner to assess for urine retention.
The nurse assessing a client with a permanent ileostomy expects to find a half-full ileostomy bag with _____ feces.
liquid
The purpose of FOBT or "Fecal Blood ____ Test" is to detect the presence of hidden blood in the stool, which may be an indication of gastrointestinal bleeding or colorectal cancer.
occult
To effectively eliminate urine, a client must produce an average of at least _ milliliters of urine each hour.
30
The large intestine is in chargeof the _____of fluids.
Réabsorption
The term ____ means emptying the bladder
micturition
Which statement describes diuresis?
Excretion of a high volume of urine.
You are taking care of an older adult client who is unable to move independently due to a stroke infection l month ago. What complications of immobility should the nurse watch out for?
Discoloration or reddening part of the sacrum.
Which option should the nurse include in teaching a client with colostomy about foods that may help to control diarrhea?
pasta
During ________ a machine is used to filter harmful wastes, electrolytes, and fluid from the blood which would typically be eliminated in the client's urine by healthy kidneys.
hemodialysis
The nurse is assessing a 37-year old client who is on a 4-day-postoperative following exploratory laparotomy. The nurse noted a moderate pinkish exudate on the dressing. This drainage is known as
Serosanguineous
A client with diabetes mellitus type 1 reports painful foot. The nurse assessing this client understands that an increase in neutrophils and localized swelling are indications of___
infection
Among the following laboratory values, which one would affect the healing of wounds caused by pressure ulcers?
Serum albumin of 3.0 grams per deciliter.
Which nursing intervention is essential to further prevent skin breakdown for a client with Stage 1 pressure injury affecting both heels?
Use bilateral heel protectors.
A nurse is educating a client about the factors that contribute to the development of constipation. The nurse should include which of the following?
Use of anesthesia, pregnancy, and immobility
What kind of dressing should the nurse apply when caring for a client who has a central venous access site in place?
transparent films
What is the best indicator that a student nurse can differentiate between excoriation and pressure ulcers?
Pressure ulcers are deeper and worse than excoriation.
What nutrient that is essential for repairing and growing tissues should the nurse include when educating a client about foods that promote wound healing?
protein
A thick and milky discharge from a wound that often indicates an infection is called _ drainage.
purulent
A nurse is assessing a client who has a pressure ulcer. The manifestation of stage ___ pressure ulcer includes full-thickness skin loss with necrotic subcutaneous tissue.
three
Which nursing intervention is most appropriate for preventing pressure injuries in a client who is at risk?
assess the skin of the client on a daily basis
Which position is commonly used for procedures such as enemas, rectal exams, and colonoscopies?
sim’s position
Which nursing action would be appropriate to slow down the rate of an enema during administration?
Lower the height of the enema container.
Prior to changing the wound dressing for a client with a painful wound, the nurse anticipates providing the client with ____ medication to promote comfort during the procedure.
pain
A nurse informs a client who has a pyloric obstruction that the insertion of a nasogastric (N.G.) tube can aid in relieving the pressure in the stomach. Which definition best describes pyloric obstruction?
A narrowing of the opening between the stomach and the small intestine.
A client is being assessed by a nurse following a colon surgery. The nurse should focus on reassessing for _sounds based on the effects of anesthesia and manipulation of the bowel during surgery.
bowel
A __________ means collecting all the urine in a special container over the course of an entire day.
24 hr urine collection
Peristalsis is controlled by the
nervous system
Order of auscultation
RLQ,RUP.LUQ,LLQ
increases peristalsis and exacerbates chronic condition
Emotional distress
decreases peristalsis
epression
IAPP
inspection, auscultation, percussion, palpation
collect 3 times, 3 different samples
Blue result- positive
Make sure all collection are correctly labeled
Guiac test
varices, tears
Esophagus
ulcers, acute gastritis
Stomach
ulcers
Duodenum
Retention oil enema
lubricate stool
Carminative retention eneme
expel flats
Anthelmintic retention enema
for parasites
Medicated retention enema
provide medications absorbed through rectum
Colostomies
end in colon
end in ileum (liquid stool)
Ileostomies
due to cancer & other bowel diseases
End stomas
to resolve medical emergencies (temporary)
Loop colostomies
Assessment for urinary elimination
frequency, urgency, duration, color, order, discharge
Condom cath
secure to shaft, never to tip
Coude cath
for clients with enlarged prostate
Transient
appears suddenly and last 6 months
two or more types of incontinence
Mixed
never getting the urge to go & overflowing
Overflow
trouble getting to the bathroom
Functional
nerve damage, ex: spinal cord injury
Reflex
hardest to treat, we don't know why it happens
total
happens to women that have had multiple births
stress
bladder doesn't allow them time to get to the bathroom
Urge
can change odor, monitor for loose stools & rash
Antibiotics
treat urinary incontinence
TAC
bladder analgesic
Phenazopyridine
many SE, increases blood supply to bladder
Hormone replacement therapy