LC

Meeting Basic Physiologic Needs Flashcards

Meeting Basic Physiologic Needs

Review Questions

Question 1: Incontinent Patient - Priority Action

The priority action for a nurse caring for an incontinent patient is to gather data to find the cause of the incontinence.

  • Why? Determining the underlying cause is crucial for developing an effective management plan.
  • Incorrect Options:
    • Helping the patient void every 2 hours: This is a potential intervention, but addressing the cause is more important.
    • Decreasing fluid intake: This can lead to dehydration and might not solve the incontinence issue.
    • Encouraging expression of embarrassment: Addressing emotional needs is important, but the physical problem needs to be addressed first.

Question 2: Midstream Urine Specimen - Greatest Concern

The urine characteristic of greatest concern in a midstream urine specimen is dark brown color.

  • Why? Dark brown urine can indicate serious conditions like kidney disease, liver problems, or severe dehydration.
  • Incorrect Options:
    • Slight ammonia smell: Normal due to urea breakdown.
    • Dilute urine: Can indicate overhydration, diabetes insipidus, or kidney problems, but not as alarming as dark brown.
    • Slightly cloudy urine: Could be due to phosphates, epithelial cells, or mild infection, but less concerning than dark brown.

Question 3: Male Patient with Urinary Retention - Before Catheterization

Before catheterization, the nurse should perform a bladder scan to determine the amount of urine retained.

  • Why? A bladder scan provides a non-invasive way to assess the amount of urine in the bladder, helping to confirm urinary retention and guide the decision to catheterize.
  • Incorrect Options:
    • Condom catheter: Not appropriate for retention.
    • Waiting 2 hours: Delays intervention and can cause discomfort.
    • Drinking water: Will worsen retention before catheterization.

Question 4: Catheterizing a Male Patient - Resistance Met

If resistance is met when catheterizing a male patient, the nurse should ask the patient to take a deep breath and slowly exhale as the catheter is inserted.

  • Why? This technique can help relax the sphincter muscles, allowing easier catheter passage.
  • Incorrect Options:
    • Applying more pressure: This can cause trauma to the urethra.
    • Using a Coudé catheter: May be necessary if simple measures fail but not the first action.
    • Discontinuing: Premature; try relaxation techniques first.

Question 5: Bladder Irrigation - Clamping the Tubing

The best rationale for clamping the tubing during bladder irrigation to instill medication is to prevent the solution from going directly into the bag.

  • Why? Clamping ensures the medication remains in the bladder for the intended duration to exert its therapeutic effect.
  • Incorrect Options:
    • Standard procedure: While it is standard, the reason matters.
    • Maintaining sterility: Important, but not the primary reason for clamping.
    • Preventing urine reflux: A secondary benefit, but not the main reason.

Question 6: Clean Catch Method - Patient Understanding

The statement that indicates an understanding of how to perform the clean catch method for a urine specimen is: "I should clean myself first, pee a little into the toilet, and then pee into the cup."

  • Why? This statement correctly describes the process of cleaning the perineal area, initiating urination to flush the urethra, and then collecting the midstream urine in the cup.
  • Incorrect Options:
    • Peeing and then cleaning: This would contaminate the sample.
    • Filling the cup completely: Only a small amount is needed.
    • Keeping the kit sterile: While important, this isn't the core instruction.

Question 7: Post-Prostatectomy - Increasingly Red Urine

If a patient who had a resection of the prostate gland yesterday and has a three-way catheter for continuous irrigation has draining urine that is increasingly red, the nurse needs to increase the rate of flow of the irrigation solution.

  • Why? Increasing the irrigation rate helps to flush out the blood and prevent clot formation in the bladder.
  • Incorrect Options:
    • Notifying the surgeon: Necessary if bleeding is excessive or doesn't respond to increased irrigation.
    • Increasing fluid intake: Hydration is important, but irrigation directly addresses the bleeding.
    • Emptying the drainage bag: Important, but not the immediate solution.

Question 8: 24-Hour Urine Specimen - Discarded Urine

If the nursing assistant discards some of the urine that should have been saved for a 24-hour urine specimen, the most appropriate nursing action is to notify the charge nurse and restart the test.

  • Why? The accuracy of the 24-hour urine test is compromised if any urine is discarded, necessitating a restart.
  • Incorrect Options:
    • Reprimanding the assistant: Address later; focus on patient needs first.
    • Extending the collection: This won't correct the missed sample.
    • Continuing the collection: The results would be inaccurate.

Question 9: Urinary Catheter Removal - Correct Order of Actions

The correct order is:

  1. Check provider order
  2. Perform hand hygiene and don gloves
  3. Position patient in high-Fowler position
  4. Place towel under the catheter; attach syringe to the balloon port of the catheter
  5. Withdraw water from the balloon until resistance is met
  6. Gently remove catheter
  7. Inspect catheter to make sure it is intact
  8. Remove gloves, perform hand hygiene, and make patient comfortable
  9. Measure and record urinary output
  10. Document procedure