PNR 221
A client with multiple sclerosis is being taught how to perform
self-catheterization. As part of this teaching, the nurse instructs the client to do
which of the following? (Select ALL that apply.) - a) Use clean technique
b) Increase fluid intake
A female client is having difficulty voiding after a vaginal delivery. The nurse
implements which of the following interventions to promote voiding? (Select
ALL that apply.) - a) Turning the water tap on
b) Ambulating the client to the bathroom
c) Trickling warm water on the genitals
A nurse directs a patient how to provide a sputum specimen. Which statement
below will be part of the instructions to the patient? - a) Take a few deep
breaths before coughing up specimen
A patient has been receiving g 100% oxygen therapy for server days. His o2
stats are dropping and he has SOB. He is extremely restless and states he
has pain beneath his breast bone. The nurse should suspect what? - oxygen
toxicity
A post op client has self-administered the maximum morphine on their PCA
(patient-controlled analgesia) pump. The nurse has assisted the client on and
off the bedpan two or three times an hour for the past two hours. Urine output
was about 50 mL with each void. The nurse now begins to suspect which of
the following? - retention overflow
After a severe accident, involving crushing injuries to legs and pelvis, john has
become a paraplegic and lost control over his bladder. He reports that the
urine trickles out in small volumes continuously. - total incontinence
All of the following conditions can lead to hypoxia except: - a) Hyperventilation
anuria - absence of urine
atelectasis - collapsed or airless alveoli
Bernadette has spina bifida and needs to catharize herself 4-6 times each day
due to a neurogenic (or spastic) bladder - Straight catheter
, catheter care: - -Minimize risk of infection:
-Good hand hygiene!!
-Remove catheter as soon as possible - Dr order needed!!!
-Keep drainage bag OFF the floor
catheter choice - = smallest effective size
catheterization - male - ØHold penis perpendicular to body, insert catheter 17 -
22.5cm until urine returns, then advance an additional 2.5 - 5cm. Inflate
balloon. Gently pull back.
catheterization at home - clean technique is used
catheterization in hospital - sterile technique is used
catheterization- female - Using dominant hand, insert catheter 5 - 7.5cm until
urine return, then advance an additional 2.5 - 5cm. Inflate balloon. Gently pull
back.
Causes of Atelectasis include - - Bronchiole obstructions such as from
retained secretions
- Decreased lung volumes (i.e. shallow breathing patterns) (eg/ post op,
immobile patients, increased abdominal pressure) and
- Diminished surfactant (eg/ preemies, smokers)
causes of dyspnea - Any condition that affects decreases oxygen level in the
blood.
Causes of transient incontinence - delirium, infection, urethritis or vaginitis,
side effects of medications, endocrine disorders, restricted mobility, stool
impaction
causes of urge incontinence - CNS disorders, bladder disorders, spinal
disorders, bladder outlet obstruction, idiopathic (unknown origin)
clubbing of fingers? - distal phlangx of each finger is rounded and bulbous,
and the angle at the bottom of the nail bed increases to 180° or more
A client with multiple sclerosis is being taught how to perform
self-catheterization. As part of this teaching, the nurse instructs the client to do
which of the following? (Select ALL that apply.) - a) Use clean technique
b) Increase fluid intake
A female client is having difficulty voiding after a vaginal delivery. The nurse
implements which of the following interventions to promote voiding? (Select
ALL that apply.) - a) Turning the water tap on
b) Ambulating the client to the bathroom
c) Trickling warm water on the genitals
A nurse directs a patient how to provide a sputum specimen. Which statement
below will be part of the instructions to the patient? - a) Take a few deep
breaths before coughing up specimen
A patient has been receiving g 100% oxygen therapy for server days. His o2
stats are dropping and he has SOB. He is extremely restless and states he
has pain beneath his breast bone. The nurse should suspect what? - oxygen
toxicity
A post op client has self-administered the maximum morphine on their PCA
(patient-controlled analgesia) pump. The nurse has assisted the client on and
off the bedpan two or three times an hour for the past two hours. Urine output
was about 50 mL with each void. The nurse now begins to suspect which of
the following? - retention overflow
After a severe accident, involving crushing injuries to legs and pelvis, john has
become a paraplegic and lost control over his bladder. He reports that the
urine trickles out in small volumes continuously. - total incontinence
All of the following conditions can lead to hypoxia except: - a) Hyperventilation
anuria - absence of urine
atelectasis - collapsed or airless alveoli
Bernadette has spina bifida and needs to catharize herself 4-6 times each day
due to a neurogenic (or spastic) bladder - Straight catheter
, catheter care: - -Minimize risk of infection:
-Good hand hygiene!!
-Remove catheter as soon as possible - Dr order needed!!!
-Keep drainage bag OFF the floor
catheter choice - = smallest effective size
catheterization - male - ØHold penis perpendicular to body, insert catheter 17 -
22.5cm until urine returns, then advance an additional 2.5 - 5cm. Inflate
balloon. Gently pull back.
catheterization at home - clean technique is used
catheterization in hospital - sterile technique is used
catheterization- female - Using dominant hand, insert catheter 5 - 7.5cm until
urine return, then advance an additional 2.5 - 5cm. Inflate balloon. Gently pull
back.
Causes of Atelectasis include - - Bronchiole obstructions such as from
retained secretions
- Decreased lung volumes (i.e. shallow breathing patterns) (eg/ post op,
immobile patients, increased abdominal pressure) and
- Diminished surfactant (eg/ preemies, smokers)
causes of dyspnea - Any condition that affects decreases oxygen level in the
blood.
Causes of transient incontinence - delirium, infection, urethritis or vaginitis,
side effects of medications, endocrine disorders, restricted mobility, stool
impaction
causes of urge incontinence - CNS disorders, bladder disorders, spinal
disorders, bladder outlet obstruction, idiopathic (unknown origin)
clubbing of fingers? - distal phlangx of each finger is rounded and bulbous,
and the angle at the bottom of the nail bed increases to 180° or more
