Renal Disorders and Wound Care: A Comprehensive Guide for Nurses, Exams of Nursing

Download Renal Disorders and Wound Care: A Comprehensive Guide for Nurses and more Exams Nursing in PDF only on Docsity! Nursing 122 Exam #3 Questions with Verified Answers 100% NPO patient’s diet - Correct Answer-Nothing per mouth patients can have IV fluids to maintain hydration and a minimally supportive caloric intake Regular diet - Correct Answer-Appropriate for patients without special nutritional needs. Provides about 2,000 calories per day and offers a balanced meal plan. Diets modified by consistency - Correct Answer-Clear liquid diet Full liquid diet Mechanical soft diet Pureed diet Clear liquid diet - Correct Answer-Orders to provide hydration and calories in the form of simple carbohydrates that help meet some of the body energy needs *Water * Broth/bouillon * Black coffee * Tea * Carbonated drinks * Clear fruit juices (apple, grape, cranberry, gelatin) * Pop-sickles * Clear sports drinks (gator aid) * Electrolyte drinks (Pedialyte) Full liquid diet - Correct Answer-Consist of all the liquids found in a clear liquid diet with the addition of all other opaque liquids and food items that become liquid at room temperature. -all clear liquids - Cream soups - Milk - Cream - Ice cream - Yogurt - Milkshakes - Sherbet - Custards/puddings -vegetable juices - pureed vegetables - All fruit juices - Protein drinks - Liquid supplements - Refined cooked cereals (cream of wheat, malt-meal) Mechanical soft diet - Correct Answer-The diet of choice for patients with acute or chronic difficulties with chewing, such as those with jaw problems, missing teeth, poorly fitting dentures, or severe weakness or fatigue - All liquids and pureed foods - All soups - Ground/ finely diced meats - Finely diced/ flaked fish - Cottage cheese - Soft cheese - mashed or rice’s potatoes - Rice -oatmeal - grits - pancakes - Soft breads - Soda and graham crackers - cooked soft vegetables - Cooked or canned fruit - Bananas - Soft patties Pureed diet - Correct Answer-One that is processed in a blender/ food processor - All liquids - Scrambled eggs - pureed meats - pureed vegetables - pureed fruits - mashed potatoes - Gravy - Applesauce - Baby foods Diabetic diets - Correct Answer-Used to manage calorie and carbohydrate in take for patients with diabetes mellitus, primarily those who are insulin dependent Calorie restricted - Correct Answer-Used for those patients who must lose weight Sodium restricted - Correct Answer-Used for those patients with hypertension, congestive heart failure, or kidney or liver failure, as we as those who require help to prevent or correct fluid retention. Fat restricted - Correct Answer-Used for patients who are experiencing problems with fat malabsorption such as those with disorders affecting the gallbladder, liver, lymphatic system, pancreas, or intestines. It also may be used for those patients who have * act immediately if you suspect a patient may be hemorrhaging internally or externally Inflammatory phase - Correct Answer-Occurs when the wound is fresh and includes both hemostasis and phagocytosis. pg. 529 Reconstruction phase - Correct Answer-When the wound begins to health and lasts for about 21 days after the injury Maturation phase - Correct Answer-Remodeling phase occurs when the wound contracts and the scar strengthens. Purpose types and sizes of catheters - Correct Answer- Straight catheter - Correct Answer-Also called a single-lumen, used only for insertion into the urinary bladder to obtain a sterile urine specimen or a onetime drainage of urine from the bladder. pg. 673 Indwelling catheter - Correct Answer-Double-lumen remains in the urinary bladder for a designated period of time. Three way catheters - Correct Answer-Triple-lumen used in only one specific situation, after a male has had a transurethral resection of the prostate the surgeon will inset a triple lumen catheter with a 30 to 60 ml balloon. Code catheter - Correct Answer-Specifically to accommodate an enlarged prostrate in male patients. It has curved tip allowing it to more easily pass through an enlarged prostate gland and enter bladder Suprapibic catheter - Correct Answer-Placed after trauma or surgery to the urethra or is an indwelling catheter cannot be interred into the bladder Condom catheter - Correct Answer-Used for males who are incontinent of urine to avoid the risk of infection related to insertion of an indwelling catheter Assisting patients with toileting - Correct Answer-* offer the opportunity to use the bathroom or bedpan before and after meals and at bedtime * Male patients may use a urinal for voiding, some men find it difficult to void while sitting or lying in bed. * use a fracture pan which is smaller and flatter for patients who have had a hip or back surgery. The pan may also be used for patients who are very thin or if a regular bedpan causes back discomfort, in that situation the patient may be rolled from side to side to place the fracture pan * provide patients with privacy and avoid rushing them * offer patients the opportunity to perform hand hygiene after toileting Bladder training - Correct Answer-- ensures the patient is taking in adequate amounts of fluid at least 64 oz. per day to help maintain a healthy urinary tract and facilitate the elimination of west - teach patients to avoid caffeinated beverages and to drink more during the day and less in the evening to prevent nighttime incontinences - Offer fluids through the day avoiding a large volume of fluid all at one time. - assist the patient to the bathroom or offer a bedpan every 2 hours and asses the patient frequently for incontinence - Most people void in the morning after meals, and before bed. Normal voiding patterns - Correct Answer-Urinating 4-6 times a day and does not routinely get up during sleep hours to void. Maturate - Correct Answer-Void or to urinate Measuring intake and output - Correct Answer-3omL per hour or 24omL in 8 hours Oliguria - Correct Answer-defined as urinary output of less than 30mL per hour Polyuria - Correct Answer-Increased urinary output, greater than 3,000mL per day Anuria - Correct Answer-Absence of urine production Dialysis - Correct Answer-Process of using a machine to filter waste products and salts and to remove excess fluid from the blood Renal calculi - Correct Answer-Kidney stones Urinary retention - Correct Answer-Inability to empty the bladder at all or the inability to completely empty the bladder Residual urine - Correct Answer-Urine that remain in the bladder after the patient voids Nocturnal - Correct Answer-Wakes up during the night to urinate Incontinence - Correct Answer-Inability to control the passing of urine in urination Stress incontinence - Correct Answer-increased abdominal pressure which causes urine to leak out of the bladder Urge incontinence - Correct Answer-The inability to keep urine in the bladder long enough to get to the restroom. Overflow incontinence - Correct Answer-Occurs when the bladder is distended due to an obstruction which prevents the bladder from emptying normally. Functional incontinence - Correct Answer-When the person is unable to reach a bathroom to urinate Total incontinence - Correct Answer-Loss of urine with no warning Neuropathic incontinence - Correct Answer-Occurs when the nerves that control the bladder and surrounding structures are not getting the message to the brain that the bladder is full Steatorrhea - Correct Answer-Stool that is fluffy floats on water, and has a foul odor due to an abnormally high content of undigested fat, crones disease Pancreatic cancer, and pancreatitis - Correct Answer-Stool that is yellow and greasy and has a foul odor Compression on the colon by a tumor, color cancer - Correct Answer-Ribbon-shaped stool Inflammation or infection of the intestinal mucosa - Correct Answer-Stool that contains blood, mucus, and pus Parasite eggs - Correct Answer-Stool may contain thread-like worms and granules Liver or gall bladder disease - Correct Answer-Stool that is pale or clay colored indicated a lock of bile in the intestines, takes antacids or drinking barium for test can also cause stool to be white Hemorrhoids - Correct Answer-Small amounts of bright red blood in the stool may Hemorrhage from the colon - Correct Answer-Larger amounts of bright red blood in the stool Bleeding from the small intestine - Correct Answer-Large amounts of maroon-colored blood Melena - Correct Answer-Stool that is black and tarry with a foul odor indicated bleeding from the stomach the blood has been partially digested giving it the black tarry appearance Constipation - Correct Answer-Less frequent, hard, formed stools that are difficult to expel, can also include a bloated feeling Factors that contribute to constipation - Correct Answer-- decrease activity level -changes in food intake - Decreased fluid intake - Medication side effects Deep tissue pressure injury - Correct Answer-Deep red, maroon, or purple in color and does not blanch, may form a blood filled or thin blister that overrules a dark wound bed. Types of designs - Correct Answer-pg. 538-539 Laceration - Correct Answer-Open wound made by the accidental cutting or tearing of tissue. Contusion - Correct Answer-Closed discolored wound caused by blunt trauma better known as a bruise Abrasion - Correct Answer-a superficial open wound, scraps, scratched or rub-type wounds where the skin is broken Puncture wounds - Correct Answer-open wound that results when a sharp item such as a needle or nail pierces the skin. Penetrating wounds - Correct Answer-Similar to puncture wound difference is that the offending object remains embedded in the tissue. Pressure injuries - Correct Answer-wound resulting from pressure and friction. Clean - Correct Answer-Wound that is not infected Clean-contaminated - Correct Answer-Would that was surgically made and is not infected but it has direct contact with the normal flora in either the repartee tract, unitary tract or gastrointestinal tract, has more potential to become infected Contaminated - Correct Answer-Can be a surgical would or a would cause by trauma that has been grossly contaminated by breaking asepsis Infected - Correct Answer-One which the infectious process is already established as evidence by high numbers of microorganisms and either purulent drainage pr necrotic. Colonized - Correct Answer-Wound differs from an infected wound in that it has a high number of microorganisms present but is without signs of infection Ischemia - Correct Answer-Tissues and capillaries are compressed resulting in reduced blood flow to the area Erythema - Correct Answer-Increased capillary blood flow associated with inflammation Granulation tissue - Correct Answer-New tissue, extremely fragile Sinus tract - Correct Answer-channel or tunnel that developed between 2 cavities or between an infected cavity and the surface of the skin sometimes known as a fistula. Debridement - Correct Answer-Infection treated with antibiotics and surgical removal of the dead tissue Methicillin resistant - Correct Answer-Extremely serious tissue Defiance - Correct Answer-Partial or full operation of the outer layer of a wound Evisceration - Correct Answer-Abdominal organs protrude through suture line Hemorrhage - Correct Answer-Bleed profusely Nursing interventions to prevent pressure injuries - Correct Answer-* reposition patient at least every 2 hours to prevent pressure and compromise of circulation to the area * Keep the skin clean and dry * Asses and incontinent patient’s incontinent pads every hour * Keep linens free of wrinkles * For immobile patients apply lotions to dry skin and asses pressure points for erythema every 1-2 hours * Lift patients who cannot move themselves with draw sheet * Remove linens from underneath a patient by rolling him to her to one side and folding the linens to the center of the bed * encourage adequate fluids and nutrition * Use specialty bed and devices to help decrease pressure injuries. Reasons for and type of alternative bowel elimination - Correct Answer-Colostomy- stoma will have a single opening termed a single-barreled or end stoma Ileostomy- Diversion created in the ileum portion of the small intestine Assessments to make about urine - Correct Answer-Color and appearance PH Specific gravity Odor Bacteria Protein Leukocyte Nitrites Glucose Ketones How to monitor intake and output - Correct Answer-Measure and record all fluids take in and all fluid volumes that is lost