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Funds. Rinal Review
Terms in this set (47)
How do you perform a clean catch urine sample for male and female?
The client must the genitalia cleaned before collecting the sample, catch mid-stream.
Keep foreskin on uncircumcised males pulled back.
Separate the labia for women. Women must be cleaned from front to back.
When is the best time of the day to perform a clean catch urine sample?
In the morning
What is the purpose of a bath?
When do you assess pain?
When you do vitals and any other time that is needed.
When do you reassess after an intervention of pain?
Reassess for pain 30-60 minutes after intervention for pain.
What are the complications of pain?
Pneumonia is a complication of pain. Because you're not moving and you are breathing shallow and fluid will accumulate.
When assessing the heart, where do you auscultate the Pulmonic, Aortic, Tricuspid, and Mitral valves?
Aortic (Base Right): 2nd ICS right sternal border
Pulmonic valve (Base Left) 2nd ICS left sternal border
Tricuspid valve (Left Lateral) 4th ICS left sternal border
Mitral valve (Apex) 5th ICS MCL
What is the order of an abdominal exam?
Assess make sure that there is no distention, and the skin appears taut.
Distention can be normal such as pregnancy; however, the may also be due to gas or fluid retention or to bowel obstruction.
Listen for bowel sounds in several areas in all four quadrants of the abdomen. Start in lower right quadrant, moving to upper right quadrant, then to the upper left, and then lower left????
Listen for a full 5 before concluding that bowel sounds are absent.
If the client complains of abdominal pain, but has normal bowel sounds what also should be considered?
Assess the bladder; there are more than just intestines in the abdominal cavity.
Explain the relationship between Type 1 Diabetes, Ketones and Hyperglycemia?
Ketones are an alternative fuel source for diabetics. The fat is broken down into Ketones.
Type 1 Diabetes the body does not make insulin.
Hyperglycemia the blood glucose is greater than 109 mg/dl fasting or greater than 126 mg/dL at random. This may be a sign of diabetes mellitus, an endocrine problem, which may develop as a result of either insufficient insulin production or resistance to the existing supply of insulin.
When the body is in a hyperglycemic state the body will break down fates into ketones to be used as an alternative fuel.
What can cause UTI's?
A bad bacterium migrates up the urethra causing a UTI. Wearing tight close puts you at a higher risk for a UTI because it brings and keeps the bacteria close to the body.
Who may have urination problems?
If your patient is getting up several times at night to empty bladder is a symptom of a urinary problem.
How do you help a client regain continence?
There are many things to assist your client with regaining continence; however, restriction of fluid is NOT one of them.
When obtaining a client's history what should you ask about elimination statues? (You want to take a elimination history)
How often do you urinate in a 24 hour period? Has that changed recently?
How often do you get up during the night to urinate?
Have you noticed any recent changes in the amount or appearance of your urine?
How often do you experience vomiting, diarrhea, or constipation? Describe your experience.
Do you have any wounds? If so, where are they, and how did they happen? What is the color of drainage and how much drainage are you experiencing?
Do you have any breaks in your skin? If so, describe the problem, and show me the area.
If a client has diarrhea, what is the health goal?
Return to normal BM pattern.
If a client has a new stoma that does not produce a BM in the allotted time, what should the RN do?
Assess for bowel signs and notify doctor of problem. (Put surgeon on notice that this recovery is not following the normal pattern)
Phantom pain is pain that is perceived to originate from an area that has been surgically removed.
Psychogenic pain refers to pain that is believed to arise from the mind.
Acute pain has a short duration and is generally rapid in onset. This type of pain is most frequently associated with injury or surgery. It is protective in that it indicates potential or actual tissue damage
Chronic pain is pain that has lasted 6 months or longer and often interferes with daily activates. Unlike acute pain, chronic pain is often viewed as insignificant by family and care providers. It may lead to patient withdrawal, depression, anger, frustration, and dependence.
Intractable pain is both chronic and highly resistant to relief. This type of pain is especially frustrating for the patient and care provider. It should be approached with multiple methods of pain relief. (Sever and will not go away)
What nursing diagnosis would be appropriate for COPD?
Impaired gas exchange
What position do you put a client into if they are having difficulty breathing?
What are some physical signs of chronic asthma?
Coughing, difficulty breathing, wheezing, short of breath, fatigue, inflammation, dyspnea, tightness, pain, clubbing and barreled chest
What causes wheezing?
Wheezing is due to inflammation in the airways. Wheezes are high pitched, continuous musical sounds, usually heard on expiration. They are caused by narrowing of the airways. Wheezes can often be heard without a stethoscope.
How do you make a nursing diagnosis more specific?
Add related to R/T
Impaired mobility R/T right knee injury
Impaired mobility R/T (with whatever part of body is injured)
What organ needs glucose almost exclusively?
The brain uses glucose exclusively and is stored in the liver and in skeletal muscle.
Glycogen is stored in the liver.
Glycogen is converted back into glucose to meet energy needs. This process is called glycogenolysis.
Complex carbohydrates consist of long chains of saccharides, called polysaccharides. Dietary fiber, a poly saccharide, is the indigestible "fibrous skeleton": of plant food.
Can you give a half a suppository?
What labs would be reviewed for a client complaining about chronic fatigue?
Hemoglobin and Hematocrit
What are SSRIs?
Selective Serotonin Reuptake Inhibitors
What types of pain are SSRI's used to treat?
SSRI's are used to treat chronic pain. They are used to reduce the dose of opioids.
What is the purpose of QSEN and NANDA?
Strive to increase safety in health care
What are high alert medications?
Heparin and insulin
What should the RN do when giving them?
Have a 2nd nurse verify them prior to administration.
How do you evaluate a patient who is intubated for pain?
Their blood pressure will rise.
Increase in heart rate
Increase in respiration rate
If an intubated pt has a sudden rise in BP, look for pain...
What side effect of opioids diminishes over time?
If a pain medication is ineffective, what does the nurse do?
Call doctor see if he can upgrade pain medication
If you are giving IV opioids what vital sign is most important to check?
Distraction is a method of drawing the patient's attention away from the pain and focusing on something other than the pain. It is based on the belief that the brain can process only so much information at one time.
Guided imagery is the use of auditory and imaginary processes to affect emotions and help calm and relax the patient. Acute and chronic pain, both physical and psychological, may respond to guided imagery; however, it is more effective for chronic pain.
Sequential muscle relaxation
Sequential muscle relaxation, or progressive relaxation, the person sits comfortably and tenses a group of muscles for 15 seconds and then relaxes the muscle while breathing out. After a brief rest, this sequence is repeated using another set of muscles. Patients often start at the facial muscles and work downward to the feet.
Hypnosis involves the induction of a deeply relaxed state. Once the person is in this state, the hypnotist offers therapeutic suggestions to provide relief of symptoms.
A good pain intervention for a CNA is
Can a CNA give patient teaching?
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?
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