Mark Klimek Blue Book (All) NCLEX Study Guide
Questions And Answers Verified 100% Correct
What is the most common route for organisms to enter the blader when a catheterization is used?
Up through the inside of the catheter in the days following catheterization
Name foods that make acid urine
Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What
is important about the level of the urinary drainage bag?
Never have the bag at a higher level than the bladder.
How is the catheter taped in a male client?
To the lateral thigh or abdomen
How is the catheter taped in a female client?
To the upper thigh
What urinary pH prevents UTI?
Acidity, low pH
Should the drainage bag ever touch the floor?
No
Is it ok to routinely irrigate indwelling catheters?
No
What agents are best for catheter care?
Soap and water
What is the most effective way to decrease UTI with catheters?
Keep the drainage system closed, do not disconnect junction of tubing
Give some signs of infection in a Foley catheter
Cloudy urine, foul smelling urine, hematuria
Is urinary incontinence an indication for catheterization?
No
Give three appropriate indications for bladder catheterization?
,Urinary retention, to check for residual, to monitor hourly output
What are the top 2 diagnoses for a client with a catheter? Which is #1? #1-
Potential for infection; Potential impairment of urethral tissue integrity
What is systole?
The MAXIMAL force of blood on artery walls What
is diastole?
The LOWEST force of blood on artery walls
Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm.
Two-thirds
Which artery is most commonly used to measure blood pressure?
Brachial
Can the thigh EVER be used to obtain a blood pressure?
Yes, but this is rare.
When pressure is auscultated the first sound heard is the ____________ measurement.
Systolic
The change in the character of the sounds is known as the ________
First diastolic sound
The cessation of sounds is known as the _________
Second diastolic sound
When 2 values are given in a blood pressure the first is the __________measurement.
Systolic
When 2 values are given in a blood pressue, the bottom number stands for the change in sounds
or cessation of sounds?
Cessation of sounds
What is the normal adult blood pressure?
120/80
Abnromally high blood pressure is called____________.
Hypertension
What is the pulse pressure?
,The difference between the systolic and the diastolic blood pressure
If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why?
High, venous congestion makes the arterial pressure higher (increases resistance) If
you use too narrow of a cuff the reading will be too high or low?
High
Vasoconstriction will ___________ blood pressure.
Increase
Vasodilation will ____________ blood pressure.
Decrease
Shock will ___________ blood pressure.
Decrease
Increased intracranial pressure will _________ the pulse pressure.
Increase or Widen
If my blood pressure is 190/110, what is my pulse pressure?
80 mmHg
What blood test must be done before a transfusion?
Type and cross match
What does a type and cross match indicate?
Whether the client's blood and donor blood are compatible.
What should the nurse measure before starting a transfusion?
Vital signs
With what solution should blood be transfused?
0.9 normal saline
How many nurses are requried to check the blood?
2 nurses
What happens when blood is administered with Dextrose IVs?
The cells clump together & don't flow well
If a transfusion reaction occurs what should the nurse do first?
, Stop the blood flow & start running the saline
How long can a unit of blood be on the unit before it must be started?
Less than 1/2 hour
What should the nurse do with the IV line if transfusion reaction is suspected?
Keep it open with saline
If a transfusion reaction is suspected, what two samples are collected and sent to the lab?
Urine & blood
If a unit of blood is infused through a central line it must be__________.
Warmed
Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing,
Increased Blood Pressure, Low Back Pain
Low back pain, wheezing, fever, hives
What are three types of transfusion reactions that can occur?
Hemolytic, febrile, allergic
What would you do first if you suspected transfusion reaction?
Stop the blood and start the saline
What are the signs and symptoms of a hemolytic transfusion reaction?
Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria
What are the signs and symptoms of a febrile transfusion reaction? Low back pain, shaking HA,
increasing temperature, confusion, hemoptysis What are the signs of symptoms of an allergic
reaction to a transfusion?
Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia)
Give three reasons for a blood transfusion
Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace
specific blood components
What does blood-typing mean?
Check for surface antigen on the red blood cell
When does typing and cross matching need to be done?
Whenever a client is to get a blood product. It is only good for 24 hours.
Questions And Answers Verified 100% Correct
What is the most common route for organisms to enter the blader when a catheterization is used?
Up through the inside of the catheter in the days following catheterization
Name foods that make acid urine
Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What
is important about the level of the urinary drainage bag?
Never have the bag at a higher level than the bladder.
How is the catheter taped in a male client?
To the lateral thigh or abdomen
How is the catheter taped in a female client?
To the upper thigh
What urinary pH prevents UTI?
Acidity, low pH
Should the drainage bag ever touch the floor?
No
Is it ok to routinely irrigate indwelling catheters?
No
What agents are best for catheter care?
Soap and water
What is the most effective way to decrease UTI with catheters?
Keep the drainage system closed, do not disconnect junction of tubing
Give some signs of infection in a Foley catheter
Cloudy urine, foul smelling urine, hematuria
Is urinary incontinence an indication for catheterization?
No
Give three appropriate indications for bladder catheterization?
,Urinary retention, to check for residual, to monitor hourly output
What are the top 2 diagnoses for a client with a catheter? Which is #1? #1-
Potential for infection; Potential impairment of urethral tissue integrity
What is systole?
The MAXIMAL force of blood on artery walls What
is diastole?
The LOWEST force of blood on artery walls
Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm.
Two-thirds
Which artery is most commonly used to measure blood pressure?
Brachial
Can the thigh EVER be used to obtain a blood pressure?
Yes, but this is rare.
When pressure is auscultated the first sound heard is the ____________ measurement.
Systolic
The change in the character of the sounds is known as the ________
First diastolic sound
The cessation of sounds is known as the _________
Second diastolic sound
When 2 values are given in a blood pressure the first is the __________measurement.
Systolic
When 2 values are given in a blood pressue, the bottom number stands for the change in sounds
or cessation of sounds?
Cessation of sounds
What is the normal adult blood pressure?
120/80
Abnromally high blood pressure is called____________.
Hypertension
What is the pulse pressure?
,The difference between the systolic and the diastolic blood pressure
If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why?
High, venous congestion makes the arterial pressure higher (increases resistance) If
you use too narrow of a cuff the reading will be too high or low?
High
Vasoconstriction will ___________ blood pressure.
Increase
Vasodilation will ____________ blood pressure.
Decrease
Shock will ___________ blood pressure.
Decrease
Increased intracranial pressure will _________ the pulse pressure.
Increase or Widen
If my blood pressure is 190/110, what is my pulse pressure?
80 mmHg
What blood test must be done before a transfusion?
Type and cross match
What does a type and cross match indicate?
Whether the client's blood and donor blood are compatible.
What should the nurse measure before starting a transfusion?
Vital signs
With what solution should blood be transfused?
0.9 normal saline
How many nurses are requried to check the blood?
2 nurses
What happens when blood is administered with Dextrose IVs?
The cells clump together & don't flow well
If a transfusion reaction occurs what should the nurse do first?
, Stop the blood flow & start running the saline
How long can a unit of blood be on the unit before it must be started?
Less than 1/2 hour
What should the nurse do with the IV line if transfusion reaction is suspected?
Keep it open with saline
If a transfusion reaction is suspected, what two samples are collected and sent to the lab?
Urine & blood
If a unit of blood is infused through a central line it must be__________.
Warmed
Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing,
Increased Blood Pressure, Low Back Pain
Low back pain, wheezing, fever, hives
What are three types of transfusion reactions that can occur?
Hemolytic, febrile, allergic
What would you do first if you suspected transfusion reaction?
Stop the blood and start the saline
What are the signs and symptoms of a hemolytic transfusion reaction?
Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria
What are the signs and symptoms of a febrile transfusion reaction? Low back pain, shaking HA,
increasing temperature, confusion, hemoptysis What are the signs of symptoms of an allergic
reaction to a transfusion?
Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia)
Give three reasons for a blood transfusion
Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace
specific blood components
What does blood-typing mean?
Check for surface antigen on the red blood cell
When does typing and cross matching need to be done?
Whenever a client is to get a blood product. It is only good for 24 hours.
