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NUR 2356 NUR2356: Multidimensional Care EXAM I Latest from Rasmussen
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NUR 2356 / NUR2356: Multidimensional Care EXAM IComplications of urinary elimination
- UTIs
UTI patient education
- wipe front to back
- pee before and after sex
- cleanse beneath foreskin
- provide catheter care regularly (nurses)
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should
the nurse take?
A. Check to see whether the catheter is patent
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis.
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of
the following actions should the nurse take? (Select all that apply.)
A. Restrict the client's intake of fluids during the daytime.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the next scheduled urination time.
E. Provide a sterile container for urine
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has
recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.)
A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back to clean the perineum
D. Location of the urethra closer to the anus
,E. Frequent catheterization
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions
should the nurse include? (Select all that apply.)
A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
E. Use the Credé maneuver
When you see indications of skin breakdown, what is your next action?
- Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints, wedge pillows)
What does PQRST stand for?
Palliative/Provoking
Quality
Region/Radiation
Severity
Timing
What are some nonverbal signs of pain?
- grimacing
- moaning
- flinching
- guarding
- decreased attention span
- restlessness, pacing
What do vital signs look like during acute pain?
- BP increased
- Pulse increased
- RR increased
Before nurses give a pain medication, what should they assess?
- drug interactions
- allergies
- vital signs
- side effects
, What are common side effects to pain medications?
- low BP
- low HR
- sedation
- respiratory depression
- orthostatic hypotension
- urinary retention
- nausea/vomiting
- constipation
After administering pain medication, what is the follow up?
- reevaluate pain level
- if given orally, follow up q 1 hour
- if given IV, follow up q 15 min
- check vital signs!
What are the complications related to pain management?
- anxiety
- fear
-depression
- slower healing
- slower recovery
superficial pain usually involving the skin or subcutaneous tissue
- cutaneous pain
pain in internal organs (the stomach or intestines). It can cause referred pain in other body locations
separate from the stimulus
- visceral pain
a type of neuropathic pain: sensation of pain without demonstrable physiologic or pathologic substance;
commonly observed after the amputation of a limb
- phantom pain
Arises from abnormal or damaged pain nerves. It includes phantom limb pain, pain below the level of a
spinal cord injury, and diabetic neuropathy: "pins and needles"
- neuropathic pain
Difference between acute and chronic pain?
- -acute pain: lasts less than 6 mnths, caused by something specific e.g. broken bone -
-chronic pain: lasts more than 6 mnths, caused by an underlying issue, affects ADLs
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