NURS 330 Final UPDATED ACTUAL Questions and
CORRECT Answers
)
Foods high in iron: dark leafy greens, meat, beans, tofu, sunflower seeds
CBC: Hgb - 12-18
Hct - 37-52%
RBC - 4-6
PLTS - 150-400 billion/L
WBC - 5000-10,000/mm3
Nursing Actions Anemia: Subjective Data:
Important health info
past health hx
meds
surgery
dietary hx
Functional health patterns
elimination
activity-exercise
nutritional-metabolic
health management
reproductive
Nursing Diagnosis Anemia: Fatigue, altered nutrition: less than body requirements, ineffective self-health
management
Ferrous Sulfate: Classification: Electrolyte Replacement
Use: treatment and prevention of iron deficiency anemia
SE: syncope, dyspepsia, N, V, diarrhea, GI bleeding
Take before meals.
Vitamin C enhances the effects.
,Iron-Deficiency Anemia: most susceptible young, poor diets, and women in their reproductive years.
Pressure Ulcer Contributing Factors: shearing - when skin adheres to bed and skin slides
friction - two surfaces rub together
excessive moisture
Pressure Ulcers: Stage 1 intact skin, non-blanchable redness. Skin temp, pain, tissue consistency.
may appear red, blue, or purple.
Pressure Ulcers: Stage 2 partial-thickness loss of dermis, shallow open ulcer with red wound bed, presents
as intact or ruptured serum filled blister.
Pressure Ulcers: Stage 3 full thickness skin loss involving damage or necrosis of subQ tissue that may
extend down, not through, underlying fascia, deep crater.
Pressure Ulcers: Stage 4 Full thickness loss muscle, bone, tendon, tunneling.
Pressure Ulcer Intervention: describe size, location, exudate, infection, pain, keep ulcer bed moist, debride,
adhesive membrane, ointment, wound dressing, good nutrition, teach self-care.
skin grafts, skin flaps, free flaps, musculocutaneous flaps.
*use cotton tip applicator
Care for Pressure Ulcers: Remove excessive moisture, turn every 1-2 hours, use lift sheets, position pillows
on bony prominence's
Urinary Incontinence Define: uncontrolled leakage of urine
Urine Incontinence Risks: Anything interfering with bladder or urethral sphincter
Confusion
Depression
UTI
Urinary Retention
Restricted mobility
Fecal impaction
Drugs
Urine Incontinence Drug Risks: ACE inhibitors: cough
Diuretics
Beta Blockers
Anticholinergics
Tricyclic Antidepressants
Ca Channel Blockers
Opioids
Sedatives
Antiseizure agents
Urine Incontinence Gender: Women : stress and urge
Men : prostatic hypertrophy, overflow from urinary retention
, Urinary Incontinence Diagnosis: Physical Exam:
Mobility
Cognitive Function
Pelvic Function
Urination Journal - 1 week
Factors producing urine leakage
Frequency of Nocturia
Urinalysis
UTI
DM
Urodynamic testing - evaluates storage of urine and outflow of urine
Imaging - ultrasound - may show urinary retention
Stress Incontinence: -sudden increase in intra-abdominal pressure = involuntary leakage of small
amounts of urine
-can occur during coughing, laughing, sneezing, or physical activities such as
heavy lifting, or exercising.
-leakage usually in small amounts and may not be daily
Stress Incontinence part 2: Pelvic floor exercises - kegels
weight loss if pt obese
cessation of smoking
surgery
Females:
topical estrogen
vaginal pessary
Males:
External Condom Catheter
Penile Clamp
Incontinence Aids
Urge Incontinence: -Urinary urgency precedes leakage of urine
-Uncontrolled contraction or overactivity of detrusor muscle
-CNS alteration - tumor, Parkinson's
-Bladder alteration - radiation
Urge Incontinence
-rx of underlying cause
-bladder retraining
-bowel regularity
-kegel exercises
anticholinergics; Ca Channel Blockers
Absorbent pads - disposable
CORRECT Answers
)
Foods high in iron: dark leafy greens, meat, beans, tofu, sunflower seeds
CBC: Hgb - 12-18
Hct - 37-52%
RBC - 4-6
PLTS - 150-400 billion/L
WBC - 5000-10,000/mm3
Nursing Actions Anemia: Subjective Data:
Important health info
past health hx
meds
surgery
dietary hx
Functional health patterns
elimination
activity-exercise
nutritional-metabolic
health management
reproductive
Nursing Diagnosis Anemia: Fatigue, altered nutrition: less than body requirements, ineffective self-health
management
Ferrous Sulfate: Classification: Electrolyte Replacement
Use: treatment and prevention of iron deficiency anemia
SE: syncope, dyspepsia, N, V, diarrhea, GI bleeding
Take before meals.
Vitamin C enhances the effects.
,Iron-Deficiency Anemia: most susceptible young, poor diets, and women in their reproductive years.
Pressure Ulcer Contributing Factors: shearing - when skin adheres to bed and skin slides
friction - two surfaces rub together
excessive moisture
Pressure Ulcers: Stage 1 intact skin, non-blanchable redness. Skin temp, pain, tissue consistency.
may appear red, blue, or purple.
Pressure Ulcers: Stage 2 partial-thickness loss of dermis, shallow open ulcer with red wound bed, presents
as intact or ruptured serum filled blister.
Pressure Ulcers: Stage 3 full thickness skin loss involving damage or necrosis of subQ tissue that may
extend down, not through, underlying fascia, deep crater.
Pressure Ulcers: Stage 4 Full thickness loss muscle, bone, tendon, tunneling.
Pressure Ulcer Intervention: describe size, location, exudate, infection, pain, keep ulcer bed moist, debride,
adhesive membrane, ointment, wound dressing, good nutrition, teach self-care.
skin grafts, skin flaps, free flaps, musculocutaneous flaps.
*use cotton tip applicator
Care for Pressure Ulcers: Remove excessive moisture, turn every 1-2 hours, use lift sheets, position pillows
on bony prominence's
Urinary Incontinence Define: uncontrolled leakage of urine
Urine Incontinence Risks: Anything interfering with bladder or urethral sphincter
Confusion
Depression
UTI
Urinary Retention
Restricted mobility
Fecal impaction
Drugs
Urine Incontinence Drug Risks: ACE inhibitors: cough
Diuretics
Beta Blockers
Anticholinergics
Tricyclic Antidepressants
Ca Channel Blockers
Opioids
Sedatives
Antiseizure agents
Urine Incontinence Gender: Women : stress and urge
Men : prostatic hypertrophy, overflow from urinary retention
, Urinary Incontinence Diagnosis: Physical Exam:
Mobility
Cognitive Function
Pelvic Function
Urination Journal - 1 week
Factors producing urine leakage
Frequency of Nocturia
Urinalysis
UTI
DM
Urodynamic testing - evaluates storage of urine and outflow of urine
Imaging - ultrasound - may show urinary retention
Stress Incontinence: -sudden increase in intra-abdominal pressure = involuntary leakage of small
amounts of urine
-can occur during coughing, laughing, sneezing, or physical activities such as
heavy lifting, or exercising.
-leakage usually in small amounts and may not be daily
Stress Incontinence part 2: Pelvic floor exercises - kegels
weight loss if pt obese
cessation of smoking
surgery
Females:
topical estrogen
vaginal pessary
Males:
External Condom Catheter
Penile Clamp
Incontinence Aids
Urge Incontinence: -Urinary urgency precedes leakage of urine
-Uncontrolled contraction or overactivity of detrusor muscle
-CNS alteration - tumor, Parkinson's
-Bladder alteration - radiation
Urge Incontinence
-rx of underlying cause
-bladder retraining
-bowel regularity
-kegel exercises
anticholinergics; Ca Channel Blockers
Absorbent pads - disposable
