NURC 1001: Exam #4 Study Guide (CSCC)

What color is normal for urine?

Straw yellow or clear

What colors indicates abnormal urine?

Red, Dark, cloudy

What two factors can affect the shades of urine?

1. Medication

2. Diet

What are four symptoms of UTI's?

1. Odd Frequency

2. Fever

3. Confusion

4. Discoloration of urine (Hematuria)

What are three ways a Nursing Assistant can help a resident who has a UTI?

1. Clean Stool immediately

2. Keep Catheter bag from off the floor

3. Do not open the catheter system

What are two causes of incontinence?

1. Diseases processes (Diabetes, Enlarged Prostate, Dementia, etc.)

2. Nerve interference (Stroke victims, Spinal Cord Injuries, etc)

How do Nursing Assistant's help prevent incontinence (3 Examples)?

1. Be alert to cues

2. Establish a schedule

3. Check every 2 hours

What is a catheter?

Hollow tube having small balloon at end. Balloon is inflated after catheter is inserted into bladder

Where are two ways a catheter can be stored?

1. Residents leg

2. Hangs from bed

What are three ways Nursing Assistants' can maintain continuous drainage of a catheter?

1. Observe every few hours

2. Tubing is kink free

3. Make sure resident is not lying on tubing

How do we cleanse a catheter?

Cleanse away from body and 3-4 inches of cathter tubing

True or False: Location of intestinal track can determine consistency of stool,.

True

What is the function of a bowel?

To remove solid waste from body

True or False: Standard time for signs of impaction is 3 days.

True

What are three signs stool is abnormal?

1. Tarry

2. Liquid

3. Containing blood

What are three signs of consitipation?

1. Abdominal tension

2. Discomfort

3. No recent movements

What is fecal impaction?

Hard stool in the lower bowel which prevents normal passage

What are three causes of fecal impaction?

1. Inadequate activity

2. Constant need to but cannot

3. No normal stool

What are three ways Nursing Assistants can help prevent fecal impaction?

1. Observe Bowel movements

2. Answer cues

3. Report any sudden changes

What is a colostomy bag?

Surgically created opening between colon and abdominal wall

True or False: Site of stoma determines bowel movement consistency .

True

Who establishes a cleaning schedule for a colostomy bag elimintation?

Nurse and is written into nursing care plan

What are three steps in bowel training?

1. High Fiber Diet

2. Exercise

3. Hydration (2000 mL daily)

What are three steps in bladder training?

1. Schedule voiding

2. Hydration

3. Encouragement

What are three measurements recorded for vital signs?

1. Heart Rate

2. Body temperature

3. Respiration rate

What are three reasons we record vital signs?

1. Can signal life threatening event

2. Reflect response to treatment

3. Detect changes

What is the normal body range for a oral temperature?

97.6 to 99.6 F

What is the normal body range for a Axillary temperature?

96 to 98.6 F

What is the normal body range for a Temporal temperature?

97. 6 to 99.6

True or False: A person's normal temperature decreases with age.

True

When is temperature the lowest?

in the morning

What color indicates a rectal thermometer?

red

What color indicates a oral thermometer?

blue

How long do we wait to take an oral tempature after someone who eats/drinks?

15-30 mins

Which form of temperature taking is the least accurate?

Axillary

How long does a tympanic temperatuer take?

1-2 seconds

How long does a temporal artery temperature take?

3-5 Seconds

What is the pulse?

measurement of heart rate per minute

What is bradycardia?

abnormally slow heart rate (less than 60 bpm)

What is tachycardia?

abnormally fast heart rate, over 100 bpm

What is the location we use to take a HR through a stethoscope?

Apical pulse

What are the three pulse sites?

1. Carotid (Used in CPR)

2. Radial

3. Brachial

What is the normal range for respiration rate?

12-20 breaths per minute

True or False: Best method for respiration rate is to make resident unaware.

True

What does is mean when there is labored respirations?

Difficulty breathing

What does is mean when there is noisy respirations?

Obstruction or wheezing

What does is mean when there is shallow respirations?

Small amount of air exchange

What is apnea?

absence of breathing

What are Cheyne-Stokes?

Breathing marked by apnea and gradually increasing depth and frequency

What is dyspnea?

difficulty breathing

What is blood pressure?

force of blood against arterial walls

What is systolic pressure?

the maximum pressure achieved during ventricular contraction

What is diastolic pressure?

pressure in the arteries during cardiac relaxation

What is normal blood pressure?

120/80

What is the first heart sound?

systolic pressure

What is the last heart sound?

diastolic pressure

True or False: Most women have lower blood pressures.

True

What are three factors that can affect the BP?

1. Age

2. Race

3. Diet

What is hypertension?

high blood pressure 140/90 or higher

What is hypotension?

low blood pressure (less than 90/60)

What is orthostatic hypotension?

A drop in blood pressure due to a sudden change of posture.

Why does our blood pressure change when we are older?

Arteries are less elastic, more narrow, and heart pumps less efficiently

What is COPD?

Chronic Obstructive Pulmonary Disease. Irreversible decrease in the ability to force air out of the lungs.

What can be affected by hypertension?

Can lead to stroke or heart attack

What does FAST mean?

F- face

A- arm

S- speech

T- time

If someone has a stroke on the left side of their brain, what body side could be affected?

Right side

What is coronary heart disease?

Coronary artery narrows, can lead to heart attack

What are three ways Nursing Assistants can help a resident going through vital changes?

1. Position them comfortably

2. Pace activities

3. Report any changes to Nurse

What are three things that can indicate COPD in the future?

1. Asthma

2. Emphysema

3. Chronic Bronchitis

What is the normal pulse range for the average adult?

60-100 bpm

How do you obtain an accurate weight/height on your resident?

- Always balance the scale before using it so the weights hang free.

- Have the patient empty his or her bladder.

- If the patient uses incontinent briefs, be sure the brief is dry before weighing.

- If the patient has an indwelling catheter, empty the bag before weighing.

- Weigh the patient at the same time of day each time.

- Have the patient wear the same type of garments each time.

- Use the same method and the same scale each time, if possible.

- If the patient has a cast, has recently had a cast removed, or has new onset edema, consult the nurse about possible weight discrepancies. You must learn to read the scale correctly. There are two bars on the upright scale. The balance bar should hang free to start.

hematuria

blood in urine

anuria

failure of the kidneys to produce urine

dysuria

difficulty with urination

oliguria

low urine output/less than expected

CHF

Congestive heart failure— heart's inability to pump blood effectively due to structural or functional impairments.