NSG124 Exam 1 Questions & Answers 2024/2025

NSG124 Exam 1 Questions & Answers 2024/2025 clean catch specimen - ANSWER-Use sterile container and only touch outside of container. Women: separate labia with one hand and clean meatus with other hand, using at least three sponges (saturated with cleansing solution) in front to back motion. Men: retract foreskin (if present) cleanse glans with at least three cleansing sponges. Replace foreskin. After cleaning, instruct patient to begin urinating & then continue to void into container. Initial voided urine flushes out contaminants in urethra/perineal area. Catheterization may be needed if patient is unable to cooperate with procedure. How is fluid loss/gain most accurately evaluated? - ANSWER-Daily weights 3-way Foley or triple lumen catheter - ANSWER-Bladder irrigation typically done to remove clotted blood from the bladder and ensure drainage of urine. Can be done manually on an intermittent basis or more commonly as continuous bladder irrigation. (CBI). Calcium (Ca) - ANSWER-8.2-10.2 mg/dL Potassium (K) - ANSWER-3.5-5.5 mEq/L Magnesium (Mg) - ANSWER-1.5-2.5 mEq/L Sodium (Na) - ANSWER-136-145 mEq/L 3way Foley stuff - ANSWER-Blood clots expected first 24-36 hours, but bright red blood is not. Displacement of catheter, dislodgment of lg clot, or abdominal pressure are abnormal findings. Sitting and walking for prolonged periods should be avoided, also avoid straining/Valsalva Maneuver. Oxybutynin - ANSWER-Ditropan. Antispasmodic. Indicated for Urinary symptoms that may be associated with neurogenic bladder including: Frequent urination, Urgency, Nocturia, Urge incontinence. Assessment of Urinary System - ANSWER-Past Health History: Hypertension, Diabetes, gout and other metabolic problems, connective tissue disorders (ex. Lupus), skin, upper respiratory infections, viral hepatitis, congenital disorders, neurological disorders or trauma. Note all medications, some can be "Nephrotoxic". Subjective: painful urination? Changes in color of urine? Changes in characteristics of urination (diminished, excessive)? Nocturnal? Diagnostic: BUN/Creatinine. Urinalysis. Urine Culture and Sensitivity. Objective: Inspect Abdomen. Urinary meatus for inflammation or discharge. Palpate: abdomen for bladder distention, masses, or tenderness. Percuss: costovertebral angle for tenderness. Female Urethra 1-2 inches long Male 8-10 inches long Kidneys sit from T12 to L3. Right kidney at 12th rib, slightly lower. Normal post void residual - ANSWER-50-75mL Urinary Retention Interventions - ANSWER-Double voiding: urinate, sit on toilet 3-4 minutes, and then urinate again before exiting the bathroom. Intermittent Catheterization, or perhaps indwelling if obstruction is the cause of retention. Drug Therapy. Scheduled toileting.. Nursing Management of Urinary Calculi - ANSWER-Nursing assessment. Recent or chronic UTI? Medications? Surgery? Pain? Fever? Labs? Impaired urinary elimination related to trauma or obstruction of ureters or urethra. Acute pain related to effects of stones and in adequate pain control or comfort measures. Goals, relief of pain. No urinary tract obstruction and knowledge of ways to prevent recurrence of stone. Drink at least 2 L per day. Moderate activity. Fluid intake must be higher in active person. Preventative measures for bedridden person. Strain all urine. Assist with ambulation to the bathroom with pain meds on board. Prevention of UTI - ANSWER-Take all antibiotics as prescribed to prevent reoccurring infection. Practice appropriate hygiene, including carefully cleaning the perineal region by separating the labia when cleansing. Wipe from front to back after urinating. Cleanse with warm soapy water after each bowel movement. Empty bladder before and after sexual intercourse. Urinate regularly, every 3-4 hours during the day. Maintain adequate fluid intake. Avoid vaginal douches, harsh soaps, bubble baths, powders, and sprays in the perineal area. Report to HCP s/s of UTI : fever, cloudy urine, pain on urination, urgency, frequency. Consider drinking unsweetened cranberry juice [8oz 3xqday] or taking cranberry extract tabs 300-400 mg/day for UTI prevention [this practice may not be effective in every patient]. What is TURP - ANSWER-Transurethral Resection of the Prostate is a surgical procedure involving the removal of prostate tissue using a resectoscope inserted through the urethra. Purpose is for surgical treatment of BPH [Benign Prostatic Hyperplasia] ... enlarged prostate. Nutritional Assessment - ANSWER-Anthropometric Measurements: height, weight, BMI, rate of weight change, amount of weight loss. Physical Exam: Physical Appearance, muscle mass and strength, dental and oral health. Health History: Personal/Family History, acute/chronic illness, current meds, herbs, supplements, cognitive status and depression. Diet History: Chewing/Swallowing ability. Changes in appetite/taste. Food/nutrient intake. Availability of food. Laboratory Data: glucose, electrolytes, lipid profile, BUN, albumin, prealbumin, CRP. Functional status: ability to perform basic and instrumental activities of daily living, handgrip strength, and performance tests-- timed walk tests. Gastrointestinal System Assessment - ANSWER-Mouth: Moist/pink lips. Pink and moist buccal mucosa & gingivae without plaques or lesions. Teeth in good repair. Protrusion of tongue in midline without deviation or fasciculations. Swallows smoothly. Abdomen: flat without masses or scars, no bruises. Positive bowel sounds in all four quadrants. No tenderness, nonpalpable liver and spleen. Liver 10cm right midclavicular line. Generalized TYMPANY. Anus: absence of lesions, fissures, hemorrhoids. Good sphincter tone. Rectal walls smooth/soft. No masses. Stool soft, brown, heme negative. Nursing Actions for Malnutrition - ANSWER-Collaboration with HCP/dietitian. Assess patient’s nutritional state. Increased stress, surgery, severe trauma, and sepsis may require more calories and protein. Measure height/weight on admission, routine reassess. Body weight provides clearer picture of patient’s fluid and nutritional State. PO food = calorie count. Conducive environment for eating. In between meal supplements. May need appetite stimulants such as megestrol acetate or dronabinol. Enteral or Parental feedings may be considered. gastrectomy postoperative - ANSWER-NG tube but will not drain a large quantity. Watch for fluid leakage at the anastomosis site as evidenced by elevated temperature & increased dyspnea. There can be impaired healing due to poor nutrition, IV/Oral replacement of vitamins C,D,K,B and cobalamin. Anemia is a possibility. Gastric Surgery post op - ANSWER-Bowel sounds generally absent early post op period. NG low intermittent suction or low continuous. Analgesics. Cough; deep breath. Semi fowlers. Dry dressing. Frequent mouth care. I/O. Postprandial hypoglycemia - dumping syndrome - ANSWER-Occurs postop (gastrectomy) when food/fluid pass quickly in jejunum which produces fluid shift from blood stream to jejunum. S/S feeling fullness, faintness, palpitations, nausea, discomfort during or after eating. May see diaphoresis, diarrhea, fainting... hypoglycemia Gastric Surgery Preop Teaching - ANSWER-Instruct patient in proper coughing and deep breathing. Methods of turning/positioning to prevent pulmonary complications. Demonstrate incentive spirometer before surgery. Bring CPAP to hospital. Inform patient they may have Urinary catheter, IV, SCD, teds, ambulation is important. What is ascites - ANSWER-Accumulation of fluid in peritoneal space Continues...