Fundamentals of Nursing: Potter Perry Midterm Study Guide, Exams of Advanced Education

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FUNDAMENTALS OF NURSING

POTTER PERRY MIDTERM

Florence Nightingale - Known as the first nurse epidemiologist who explored sanitation techniques and its effect on health Roles of the Nurse - Caregiver Communicator Educator Advocate Manager Caregiver - help patients maintain and regain health, manage disease and symptoms, and attain a maximal level of function Advocate - promote the patient's human and legal rights Educator - explain concepts and facts about health, describe the reason behind routine care activities, and demonstrate self care activities Communicator - Communication is the center of the nurse-patient relationship. Communication is used to gain knowledge of the patient, and to meet the need of the patient, their families, and the communities. Manager - Establish an environment for collaborative patient centered care. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or facility. Nurses in Legislation - Nurses can influence policy decisions at all governmental levels. One way is to get involved by participating in local and national efforts. This effort is critical in exerting nurses' influence

early in the political process. Legislation is not beyond the nurse's control and national program can have bearing on state politics. Benner's Stages of Nursing Proficiency - a nurse goes thorough 5 levels of proficiency when acquiring nursing skills (Novice, Advanced Beginner, Competent, Proficient, Expert) Novice - Beginner nursing student or any nurse entering a situation with no previous level of experience Advanced Beginner - A Nurse with some level of experience with a situation Competent - A nurse that has had the same clinical position for 2- 3 years Proficient - Nurse with more that 2-3 years of the same clinical position. Has gained experience from multiple situations. Expert - Nurse has diverse experience with an intuitive grasp to access clinical situations Autonomy - initiating Independent nursing interventions without medical orders Accountability - as the nurse you are professionally and legally responsible for the type and quality of care you provide Nurse Midwife - The practice of nurse-midwifery involves providing independent care for women during normal pregnancy, labor, and delivery, as well as care for the newborn. CRNA (Certified Registered Nurse Anesthetist) - Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician (health care provider) with advanced knowledge of surgical anesthesia. Nurse Practitioners - These advanced practice nurses manage self-limiting acute and chronic stable medical conditions. They may or may not work independently depending on the state regulations.

Clara Barton - Founder of the American Red Cross Dorthea Lynde Dix and Mother Bickerdyke - Cared for wounded soldiers & regulated supplies to troops during the Civil War. Dorothea Dix was one of the first mental health advocates. Harriet Tubman - Former slave who helped slaves escape in the Underground Railroad Lillian Wald and Mary Brewster - Community Nurses took care of poor in New York opened Henry House Nursing Metaparadigm - Allows nurses to understand and explain what nursing is, what nursing does, and why nurses do what they do. Nursing's metaparadigm includes four concepts: person, health, environment/situation, and nursing. Indwelling Urethral Catheter and Anesthetic Agents - Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. Indwelling Urethral Catheter and Positioning of the Patient - When inserting an indwelling urethral catheter, if the patient's condition does not allow the nurse to place the patient in the correct position for insertion, the nurse must use critical thinking skills to adapt positioning technique. Inserting an Indwelling Uretheral Catheter for a Male Patient - Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the nondominant hand (now contaminated), retract the foreskin (if uncircumcised) and gently grasp the penis at the shaft just below the glans. Hold the shaft of the penis at a right angle to the body. The Nursing Process - five-step systematic method for giving patient care; involves 1) assessing, 2) diagnosing, 3) planning, 4) implementing, and 5) evaluating Assessment Phase of the Nursing Process - The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase.

Subjective Data - •Patients' verbal descriptions of their health problems •Includes patient feelings, perceptions, and self-reported symptoms Objective Data - •Findings resulting from direct observation Two Stages of Assessment - •Collection of information from a primary source (a patient) and secondary sources •The interpretation and validation of data to determine whether more data are needed or the database is complete. Three Types of Assessment - •Patient-centered interview (conducted during a nursing history) •Periodic assessments (conducted during ongoing contact with patients) •Physical examination (conducted during a nursing history and at any time a patient presents a symptom) Assessment Data Sources - •Patient •Family caregivers and significant others •Health care team •Medical records •Other records and the scientific literature •Nurse's experience Phases of the Interview During Assessment - •Orientation and setting an agenda •Working phase (collecting data by using interview techniques, observation, open-ended questions, closed-ended questions, leading questions, back channeling, probing, and interpretation) •Termination phase Components of the Nursing Health History - •Biographical information •Chief concern or reason for seeking care •Patient expectations

•Present illness or health concerns •Past health history •Family history •Psychosocial history •Spiritual health •Review of systems •Observation of patient behavior •Diagnostic and laboratory data Rationale for Using a Standard Formal Nursing Diagnosis - * Distinguish the nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. *Provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. *A diagnosis is a clinical judgment based on information. Etiology of Nursing Diagnosis - The r/t factor - should not be a medical diagnosis Diagnostic Reasoning - Defined as a process of using the assessment data gathered about a patient to logically explain a nursing diagnosis or clinical judgement. Types of Nursing Diagnostic Statements - *Problem-focused (identify an undesirable human response to existing problems or concerns of a patient) *Risk diagnosis (diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication) *Health promotion (identify the desire or motivation to improve health status through a positive behavioral change) Defining Characteristics - Related signs and symptoms or clusters of data that support the nursing diagnosis. Revising a Care Plan - Nurses revise a plan when a patient's status changes; assessment is the first step. Know also that a plan of care is dynamic and changes as the patient's needs change.

Characteristics of a Goal - A goal is a broad statement that describes a desired change in a patient's condition or behavior. A goal is mutually set with the patient. The family is often a resource to help the patient meet health care goals. Family should be included in the plan of care as much as possible. Characteristics of an Expected Outcome - An expected outcome is a specific and measurable change that is expected as a result of nursing care. An expected outcome should be patient centered; should address one patient response; should be specific, measurable, attainable, realistic, and timed (SMART approach). Prioritizing When Planning Care - Work from your plan of care and use patients' priorities to organize the order for delivering interventions and organizing documentation of care. When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Collaborative or Interdependent Interventions - Therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Health Care Provider-initiated (HCP) Interventions - Dependent nursing interventions, or actions that require an order from the HCP. Example: administering medications Nurse-initiated (Independent) Interventions - Actions that a nurse initiates without supervision or direction from others. Using a PICOT Question to Improve Nursing Care Plans - Implementing interventions based on scientific research by using results of a literature search to a PICOT question can help a nurse decide which interventions to use. Communicating the Nursing Care Plan - The plan of care communicates nursing care priorities to nurses and other health care professionals. All health care professionals involved in the patient's care need to be informed of the plan of care. Making a Consultation When Developing a Plan of Care - Assess the situation and identify the general problem area. Direct the consultation to the right professional such as another nurse or social worker. Provide a consultant with relevant information about the problem area and seek a solution. Do not prejudice or influence consultants. Be available to discuss a consultant's findings and recommendations.

Nursing Outcomes Classification (NOC) - Nursing Outcomes Classification (NOC) links outcomes to NANDA International nursing diagnoses. Such a rating system adds objectivity to judging a patient's progress. Using standardized nursing terminologies such as NOC makes it more possible to measure aspects of nursing care on a national and international level. The indicators for each NOC outcome allow measurement of the outcomes at any point on a 5-point Likert scale from most negative to most positive. This resource is an option you can use in selecting goals and outcomes for your patients. Using Clinical Practice Guidelines or Protocols as a Tool - A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care Using Critical Thinking Throughout the Nursing Process - As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient's clinical situation. You must constantly reassess patients, reprioritize as needed, modify interventions if necessary, and evaluate the effectiveness of interventions being used. Diagnostic Phase of the Nursing Process - After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. Planning Phase of the Nursing Process - Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. Implementation Phase of the Nursing Process - During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals. Evaluation Phase of the Nursing Process - Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves and if goals have been met. Health Behavior - Health behavior involves demonstrating a psychomotor skill

When goals are not met, the nurse identifies ________. - interfering factors. Describe Standard Precautions - Use clean gloves when you anticipate contact with body fluids and nonintact skin or mucous membranes. Use gown, mask, and eye protection when there is a risk for splash. Keep bedside table surfaces clutter-free, clean, and dry when performing aseptic procedures. Clean all equipment that is shared between patients. Ensure that patients cover mouth and nose when coughing or sneezing, use tissues to contain respiratory secretions, and dispose of tissues in waste receptacle. Contact Precautions are used for: - (DORMS) Diarrheal (C dif, Rotavirus, E. coli) Other (conjunctivis, salmonella) Respiratory infections (RSV - mask if productive cough, Adenovirus, Parainfluenza - mask if coughing) Multi Drug resistant (MRSA, VRF) Skin + Wound Infections (scabies, lice, herpes simplex, varicella- uncrusted lesions, shingles- localized) Describe Contact Precautions - -private room or cohort with another of same contact isolation -wash hands before/after -Use gloves and gown -limit transport Droplet Precautions are used for: - Spiderman S- Sepsis/Streptococcal Pharyngitis P- Pneumonia/ Pertussis I - Influenza A + B D- Diphtheria E- Epiglottitis

R- Rubella M- Mumps/ Meningitis/ Meningeal Pneumonia A-Adenovirus N- Neisseria Meningitidis Describe Droplet Precautions: - Wear a surgical mask. Place a mask on the patient during transport. Patients may cohort if cultures contain the same organism. Airborne precautions are used for: - AIRS MTV Airs - Shingles (Disseminated disease or immunocompromised) M - Measles (Rubella) T - Tuberculosis V - Varicella (Chicken Pox) Describe airborne precautions: - Use N-95 or P2 mask. Single room under negative pressure. Preventing hospital associated UTI - Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross-contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. The correct order for removing personal protective equipment for a patient in a protective environment and for performing associated tasks is to: - remove gloves, remove eyewear, remove gown, remove mask, perform hand hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that prevents the spread of microorganisms. Caring for a patient in a protective environment: - Isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges/hr, and all air is filtered through a HEPA filter. Isolation disrupts normal social relationships with visitors and caregivers. Take the opportunity to listen to a patient's concerns or interests. Open drapes or shades and remove excess supplies and equipment. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms. All

health care personnel wear an N95 respirator every time they enter the room for patients, and a private room with negative airflow is required for patients on airborne precautions. Donning PPE for a sterile procedure: - To maintain sterility, touch the inside of the gown that will be against the body. Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands maintains the principle of sterile only touching sterile to open gloves. Extending the fingers fully into both gloves ensures full dexterity while using the sterile gloved hand. Gloving the dominant hand first helps to improve dexterity. Slipping the fingers underneath the second glove cuff helps to keep the gloved fingers sterile. Interlocking fingers ensures a smooth fit over the fingers Surgical cap, face mask, and eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to tie the back of the gown will contaminate the sterile area of the gown. Sterile objects held below the waist are considered contaminated. The steps for inserting an intravenous catheter are as follows: - Apply tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure. Normal calcium range is: - 8.4 to 10.5 mg/dL Calcium memory trick: Call 911 (about 9 - 11) When calcium is elevated, _______ will decrease. - Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. Changing gowns for patients with IV: - Remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. Remove the sleeve of the gown from the arm with the IV line. Remove the IV solution container from its stand, and pass it and the tubing through the sleeve. If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication. A patient experiencing respiratory depression is at risk for which acid-base imbalance: - Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis.

Excessive vomiting or gastric suction (ex. using a NG tube for suction) would put the patient at risk for which acid-base imbalance: - Metabolic alkalosis - the patient is losing acid Respiratory alkalosis should be consistent with which lab values: - an alkalotic (high) pH and decreased CO2 (respiratory) values, with a normal HCO3 -. High - low - norm Normal pH lab values: - 7.35 to 7. normal PaCO2 lab values: - 35 to 45 mm Hg Normal HCO3 lab values: - 22 to 26 mEq/L Signs and symptoms of hypokalemia are: - muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias What could a nurse expect to find in a patient who abuses alcohol: - A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). The ______ are responsible for respiratory acidosis compensation. - kidneys (renal) Metabolic acidosis should be consistent with which lab values: - an acidotic (low) pH and high CO (respiratory) values, with a low HCO3 -. low - high - low Signs and symptoms of extracellular fluid volume excess/overload (ECV excess): - Overnight weight gain, edema, full neck veins when upright, crackles in lungs

What nursing intervention should be implemented in ECV excess? - Raise the head of the bed to ease breathing Example of a hypotonic intravenous (IV) solution: - 0.45% sodium chloride An effective measure of fluid retention or loss is: - daily weights Total parenteral nutrition (TPN) is: - an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing An example of isotonic solution is: - 0.9% sodium chloride Hypernatremia is diagnosed by ______. - elevated serum sodium concentration Physical examination findings of ECF deficit include: - postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Microdrip tubing delivers: - 60 drops/mL Patients with nasogastric suctioning are at risk for - potassium deficit When calculating fluid intake, remember to record _______ of the volume of ice chips. - half When administering a blood transfusion, a _____ should be reported immediately and the blood transfusion stopped. - fever The longest a nurse could let blood infuse is over ____ hours. - four If a patient experiences an acute intravascular hemolytic reaction to a blood transfusion, the nurse should: - discontinue the blood transfusion, attach new tubing, and begin running normal saline at a rate to keep the vein open (TKO), in case any medications need to be administered via IV site.

When administering a transfusion you need: - an appropriate-size IV catheter and blood administration tubing that has a special in-line filter. Cardiac assessment is necessary in a patient experiencing which electrolyte imbalance: - hyperkalemia _______ causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. - Hypocalcemia Diabetes insipidus places a patient at risk for: - dehydration and hypernatremia Selecting a site for IV insertion: - The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage IV infiltration results in: - Edema near the IV insertion site, skin that is cool to the touch, and skin that may be pale or discolored. When removing an IV catheter, the nurse should: - stop the infusion before removing the IV catheter, keep the catheter parallel to the skin while removing it to reduce trauma to the vein, and apply pressure to the site for 2 to 3 minutes after removal. Antidiuretic hormone - Reduces excretion of water Diuretic releases water. Anti - stops/slows the release of water Angiotensin II - Vasoconstricts and stimulates aldosterone release Angio relates to blood vessels tensin (tension) constricts

Aldosterone - Reduces excretion of sodium and water Atrial natriuretic peptide - Increases excretion of sodium and water Bicarbonate - Major buffer in the extracellular fluid The body does not synthesize ______, so these need to be provided in the diet. - indispensable amino acids The simplest form of protein is the _______. - amino acid Positive nitrogen balance is required for: - growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Most _____ fats have high proportions of saturated fatty acids. - animal _______ fats have higher amounts of unsaturated and polyunsaturated fatty acids. - Vegetable Having the patient flex the head slightly to a chin-down position helps prevent _______. - aspiration when feeding Deficiency occurs when fat intake falls below ___% of daily nutrition. - 10 The ____ program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. - ChooseMyPlate Referenced Daily Intake (RDIs) include: - protein, vitamins, and minerals

The daily reference values (DRVs) consist of nutrients such as: - total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium The skill of ____ can be delegated to nursing assistive personnel. - measuring blood glucose level after skin puncture (capillary puncture) Inadequate intake of _____ during pregnancy may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. - folic acid As patients age, thirst sensation diminishes, leading to _____. - inadequate fluid intake or dehydration To adequately screen for nutritional problems, the nurse should: - combine multiple objective measures with subjective measures related to nutrition BMI greater than ____ is defined as obesity. - 30 BMI between _____ is classified as overweight. - 25 and 30 BMI from ____ is normal. - 18.5 to 24. BMI under _____ is underweight. - 18. The steps for an enteral feeding are as follows: - Place patient in high-Fowler's position or elevate head of bed to at least 30 (preferably 45) degrees; verify tube placement; check for gastric residual volume; flush tubing with 30 mL of water; and initiate feeding. To determine the length needed to insert an NG tube, measure the distance from - the tip of the nose to the earlobe to the xiphoid process of the sternum. The most reliable method for verification of placement of small-bore feeding tubes is: - xray examination.

When feeding a patient using a gastric tube, the formula/tube feeding should be - at room temperature A major cause of pulmonary aspiration is regurgitation of formula; to prevent this, the nurse should: - verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward To prevent clogging of an NG tube during medication administration, the nurse should: - Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL of water before and after each medication per tube. Completely dissolve crushed medications in liquid if liquid medication is not available. Possible causes of abdominal cramping during/following enteral feeding is - a rapid increase in rate or volume. or the use of cold formula Hyperosmolar formulas can cause - diarrhea or formula intolerance During central venous catheter dressing changes, always: - use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection of the central venous catheter, change the TPN infusion tubing every _____ and _____. - 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours. When discontinuing parenteral nutrition (PN), PN must be - tapered off gradually. Signs and symptoms of hyperglycemia are - thirst, headache, lethargy, and increased urination. The diabetic patient should limit saturated fat to less than ____% of total calories and cholesterol intake to less than 200 mg/day. - 7 American Heart Association guidelines recommend limiting trans fat to less than ____% - 1

Restorative care of malnutrition resulting from AIDS focuses on: - Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate maximizing kilocalories and nutrients. Patients benefit from eating cold foods and drier or saltier foods with fluid in between. Example of foods on a full liquid diet: - Custard, frozen yogurt, and pureed vegetables ______ has decreased drug absorption with milk and antacids and has decreased nutrient absorption of calcium from binding - Tetracycline Nutritional treatment for _____ includes a moderate- or low-residue (fiber) diet until the infection subsides. - diverticulitis Normal specific gravity is - 1.0053 to 1. A urine output of ____ mL/hr or less for 2 or more hours would be cause for concern. - 30 Oliguria is - diminished urinary output in relation to fluid intake. If a patient is experiencing oliguria, the nurse should first: - gather all assessment data to determine the potential cause Think ADPIE - Assessment is always first Urge urinary incontinence is: - the leakage of urine associated with a strong urge to void. Patients leak urine on the way to or at the toilet and rush or hurry to the toilet. Dysuria is: - burning or pain with urination.

Urinary retention is: - the inability to empty the bladder. Functional urinary incontinence is: - incontinence due to causes outside the urinary tract, such as mobility or cognitive impairments If a male patient is experiencing urinary retention, the nurse should: - assist the patient to a standing position. In an incontinent patient, if the urine has prolonged contact with the skin, _____. - skin breakdown can occur Treatment for stress urinary incontinence includes: - Perform pelvic floor exercises (kegel) Cystitis is inflammation of the bladder; associated symptoms include: - hematuria (blood in the urine), foul-smelling cloudy urine, and urgency/frequency. The steps for irrigating with a needleless closed irrigation technique is as follows: - Draw up in a syringe the prescribed amount of medication or sterile solution; clamp indwelling retention catheter just below specimen port; using circular motion, clean injection port with antiseptic swab; insert tip of needleless syringe using twisting motion into irrigation port; slowly and evenly inject fluid into catheter and bladder; and withdraw syringe, remove clamp, and allow solution to drain into drainage bag. To obtain a clean-voided urine specimen from a female patient, the nurse should teach the patient to: - hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from front to back. The initial stream flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. The urine should be collected mid-stream. Drink fluids 30 minutes before giving a specimen. Phenazopyridine is a medication that changes the color of urine to ________. - orange Riboflavin is a medication that changes the color of urine to ________. - intense yellow

Eating beets, rhubarb, and blackberries causes _____ urine. - red Dark amber urine is the result of - high concentrations of bilirubin in patients with liver disease. Fever and chills may be observed in a patient with excessive ______ in the urine. - WBCs Flank pain and calcium phosphate crystals are associated with renal calculi. An _______ allows the provider to observe pathological problems such as obstruction of the ureter. - intravenous pyelogram An intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. After the test is performed, the first nursing priority is to assess the patient for an allergic reaction to the contrast media that could be life threatening. Signs of an allergic reaction include: - fever, rash, and difficulty breathing To measure a patient's postvoid, measure within _____ minutes of voiding. Record the urine volume. - 10 When performing a postvoid scan on a woman who has had a hysterectomy, designate the patient as a ______. - male To stimulate urination in a female patient, the nurse should: - turn on a faucet and allow water to run A Coudé catheter would be indicated for a: - middle-aged male who needs bladder irrigation Key interventions to prevent catheter-associated urinary tract infections include: - placing the drainage bag below the level of the bladder to prevent urine back flow maintaining a closed urinary drainage system Avoid dependent loops in urinary drainage tubing.

Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. Using a clean washcloth, soap, and water, with your dominant hand wipe in a circular motion along the length of the catheter for about 10 cm (4 inches), starting at the meatus and moving away. Patients with reflex incontinence are at risk for developing autonomic dysreflexia, a life-threatening condition that causes _____. This is a medical emergency requiring immediate intervention; notify the health care provider immediately. - severe elevation of blood pressure and pulse rate and diaphoresis. To reduce discomfort during a closed intermittent catheter irrigation, use _____ solution. - room temperature If urine is bright red or has clots, increase irrigation rate until _______, indicating successful irrigation. - drainage appears pink A patient with a urethral stricture is most likely to have a _____ catheter - suprapubic When obtaining a 24-hour urine specimen, it is important to: - keep the urine in cool conditions, depending upon the test. The patient should be asked to void and to discard the urine before the procedure begins. Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate _________ requiring intervention - inadequate bladder emptying When newly started on an antimuscarinic, you should monitor the patient for effectiveness, watching for a decrease in symptoms such as: - urgency, frequency, and urgency urinary incontinence episodes.

_______ is a toileting schedule based upon the patient's usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. - Habit training _______ is a program of toileting designed for patients with mild or moderately cognitive impairment. Patients are toileted based upon their usual voiding pattern. Caregivers ask the patient if they are wet or dry, give positive feedback for dryness, prompt the patient to toilet, and reward the patient for desired behavior. - Prompted voiding ______ is toileting based upon a fixed schedule, not the patient's urge to void. The schedule maybe set by a time interval, every 2 to 3 hours or at times of day such as before and after meals. - Timed voiding or scheduled toileting In _______, patients are taught to inhibit the urge to void by taking slow and deep breaths to relax, perform 5 to 6 quick strong pelvic muscle exercises (flicks) in quick succession followed by distracting attention from bladder sensations. When the urge to void becomes less severe or subsides, only then should the patient start the trip to the bathroom. - bladder retraining What is the goal/expected outcome of the nurse for a patient with the nursing diagnosis of constipation related to opioid use? - The nurse's goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. After instilling saline during irrigation of a patient's nasogastric (NG) tube, immediately ______ to withdraw fluid. - aspirate or pull back slowly on syringe When caring for a patient with a colostomy bag, a _______ may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. - purple stoma