Exam 2: NR224 / NR 224 (Latest Update 2024/2025) Fundamentals: Skills Review| Complete Guide with Questions and Verified Answers| 100% Correct -Chamberlain
Exam 2: NR224 / NR 224 (Latest Update
2024/2025) Fundamentals: Skills Review|
Complete Guide with Questions and Verified
Answers| 100% Correct -Chamberlain
Q: stress incontinence
Answer:
-leakage of small amounts of urine due to increased intraabdominal pressure
-coughing, laughing, sneezing, walking
Q: interventions for stress incontinence
Answer:
pelvic muscle exercises
Q: reflex incontinence
Answer:
loss of urine when bladder reaches specific volume (spinal cord injury)
Q: S/S of reflex incontinence
Answer:
diminished/absent awareness of bladder filling &
urge to void; at risk for autonomic dysreflexia
Q: interventions for reflex incontinence
Answer:
schedules (voiding or intermittent catheterization)
Q: urge incontinence
Answer:
strong sense of urgency r/t overactive bladder (involuntary contractions of bladder)
Q: S/S of urge incontinence
Answer:
urgency, frequency, nocturia, inability to hold urine once urge felt
Q: interventions for urge incontinence
Answer:
avoid bladder irritants, pelvic muscle exercises, anticholinergics
Q: urinary diversions
Answer:
no bladder; urethra brought to surface with an opening, or stoma, and it gets collected into a
pouch
Q: skin care for patients who are incontinent
Answer:
-identify & treat skin issues
-skin risk assessment tools
-barrier products
-hydration
~don’t: only use soap & water, double pad bed, leave soiled pads in contact w/ skin
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common urinary elimination problems urinary retentionurinary tract infectionurinary incontinenceurinary diversions
urinary retention -an accumulation of urine due to the inability of the bladder to empty-partial retention or full retention
UTIs -a woman who does not know how to wipe properly -taking many baths-using highly scented soap-sitting in their stool or urine for a long time-in hospital: not following sterile technique catheterization insertion
urinary incontinence involuntary leakage of urine
functional incontinence causes outside the urinary tracttoilet access restricted by sensory impairments, cognitive impairments, mobility issues, environmental barriers
interventions for functional incontinence toileting schedule, mobility aids, clear access, call light in reach, easy clothing
overflow incontinence caused by overdistended bladder r/t obstruction or weak/absent bladder contractions
S/S of overflow incontinence distended bladder, high PVR, leakage of small volumes of urine
interventions for overflow incontinence timed voiding, intermittent or indwelling catheter
stress incontinence -leakage of small amounts of urine due to increased intraabdominal pressure -coughing, laughing, sneezing, walking
interventions for stress incontinence pelvic muscle exercises
reflex incontinence loss of urine when bladder reaches specific volume (spinal cord injury)
S/S of reflex incontinence diminished/absent awareness of bladder filling & urge to void; at risk for autonomic dysreflexia
interventions for reflex incontinence schedules (voiding or intermittent catheterization)
urge incontinence strong sense of urgency r/t overactive bladder (involuntary contractions of bladder)
S/S of urge incontinence urgency, frequency, nocturia, inability to hold urine once urge felt
interventions for urge incontinence avoid bladder irritants, pelvic muscle exercises, anticholinergics
urinary diversions no bladder; urethra brought to surface with an opening, or stoma, and it gets collected into a pouch
skin care for patients who are incontinent -identify & treat skin issues-skin risk assessment tools-barrier products-hydration~don’t: only use soap & water, double pad bed, leave soiled pads in contact w/ skin
urinary lab and diagnostic testing -urinalysis -urine culture
urinary diagnostic examinations bladder scan
physical assessment: kidneys when pt. has kidney stones they will have flank pain on their lower back sides; very tender
urine intake -all fluid and all food, anything that goes in the patient-fluid: anything that is a liquid at room temp; popsicles, jello
color of urine -pale straw to amber (indicates concentration)-hematuria (blood)-unusual colors -> medications, foods
clarity of urine -cloudy, sediment, clear-sediment, cloud or blood in urine is indicator of infection
odor of urine foul odor -> infectionsome food changes odor
urine output
a patient has voided 300ml over the last 8 hours, is this enough per hour? yes: 300/8=37.5 per hour
indwelling catheter -one lumen for balloon-one lumen for drainage of urine
how would the nurse obtain a sterile urine specimen from an indwelling urinary catheter? -clamp foley tubing, after urine accumulates-clean off the port with alcohol, attach a syringe and drawback to get the urine -NEVER get the specimen from the foley bag
if you instill 1000 ml of irrigation solution into a foley, and what comes out into the foley bag is 1900 ml of fluid. what would you document as the urine output?
closed drainage system -drainage bag connected to indwelling catheter-should NEVER be separated-drainage bag kept below level of bladder-leg bags
if not draining into bag, check: -kinks or bends in tubing-is client on tubing?-prevent tubing from becoming dependent -observe for clots or sediment that block catheter or tubing
hypoventilation
hyperventilation
hypoxia
nasal cannula 1-6 L/min24-44% O2
patient with COPD -pulse ox will be lower; 89-90%-this is normal-we don’t want them on high levels of oxygen b/c it decreases their work of breathing
clear liquid diet -clear juice (cranberry, grape, apple)-broth or bouillon-jello (gelatin)-popsicles-coffee or tea (without milk!)-carbonated beverages-honey
full liquid diet -pudding-yogurt-ice cream or sherbet-milk (all types)-cream soups (strained)-refined cooked cereals (oatmeal, cream of wheat)-all fruit/vegetable juices
dysphagia diets pureed, mechanical soft, thickened liquids-NO straws or ice
pureed diet -scrambled eggs-pureed meats, vegetables, & fruits-mashed potatoes & gravy
mechanical soft diet -easy to Chew-ground/finely diced meats-cottage cheese-rice-pancakes-cooked vegetables, cooked or canned fruits-bananas-peanut butter-soups
nasogastric NG -short term therapy-inserted via nose
implementation of NG -head of bed must be at a minimum of 30 degrees; prevent aspiration-auscultate bowel sounds-monitor tube placement; xray
doffing PPE gloves, goggles, gown, mask
maintenance & promotion of lung expansion -positioning -> frequent changes in position can reduce stasis of secretions & increase chest wall expansion-45 degree Semi-Fowler’s
what type of oxygen delivery device is a nasal cannula? low flow oxygen delivery device
incentive spirometry -encourages voluntary deep breathing through visual feedback-prevents atelectasis-5 to 10 breaths per session every hour
what are we going to educate our patients to do to oxygen being combustible? -post no smoking signs-no petroleum-based lubricant for nares or lips-cotton gown
factors influencing nutrition -sociological factors-psychological factors-environmental factors-developmental needs
nursing considerations: Judaism NO pork, predatory fowl, shellfish, rare meat; Kosher diets and not mixing dairy/meat products; Passover -> no leavened bread; Yom Kippur -> fasting; no work on the Sabbath
nursing considerations: Hinduism NO alcohol, fish, meats; vegetarianism
nursing considerations: Christianity Lent & meatless days; alcohol consumption varies
nursing considerations: Muslim NO pork, alcohol, caffeine; Ramadan & Halal
asking a female to do what before insertion of the catheter? bear down, and inform they will feel pressure
indwelling catheter: positioning of patient & bed supine position, knees flexed, lower HOB to toleranceankles up, to the side & drop knees outwardbed is also at level of hips w/ side rail down on working side of bed
foods high in fiber -fruits; raspberries & strawberries, apples, bananas-grains, cereal, pasta; whole wheat, oatmeal, brown rice-legumes, nuts & seeds; beans, pecans & almonds-vegetables; broccoli, potatoes, carrots
vitamins -fat soluble: A, D, E, K-water soluble: B Complex, C-perform specific metabolic functions based on vitamin
minerals -inorganic elements such as calcium, sodium, potassium, iron, zinc, etc.-16 essential minerals-play many different roles depending on mineral
iron -component of hemoglobin -> distributes oxygen-heme (animal) -> easier to absorb;meat (especially red meat), fish, poultry-non-heme (plant); vegetables, legumes, dried fruit, whole & enriched grains
caffeine -naturally occurring (can also be synthetic or man-made)-stimulates central nervous system-also a diuretic!
caffeine can be found in -coffee-tea-cacao (chocolate!!)-certain soft drinks (cola)-energy drinks
what is atelectasis and how do we prevent it? -collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide-prevent it by using an incentive spirometer
if a client is experiencing orthopnea while laying flat in bed, what intervention can we recommend to improve their condition short term? use multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated.
what is the first sign of hypoxia that you will observe in a patient? blood pressure is elevated
what do you do if you get an abnormal pulse ox reading that does not match your physical assessment? assess the temp for the hands and the room, take off any nail polish, check cap refill
Patient is undergoing bladder irrigation. 1000 mL of 0.9% normal saline was instilled into the patient’s bladder. The foley bag contains 1550 mL of fluid. What is the patient’s urinary output?
lung sounds for COPD crackles
lung sounds for asthma wheezes
most serious tracheostomy complication airway obstruction, which can result in cardiac arrest
limit introduction of the suction catheter… to 2 times with each suctioning procedure(this is for trach)
trach safety guidelines -perform tracheal suctioning before pharyngeal suctioning whenever possible-use caution when suctioning clients with a head injury-the use of normal saline instillation into the airway before suctioning is not recommended
clients with COPD -if they are breathing spontaneously they should cautiously receive high levels of oxygen therapy-this is ONLY if breathing spontaneously, not if their oxygen is < 95%