14 hours ago While obtaining a clean-catch midstream urine specimen, a nurse makes a mistake by. 1. Cleaning the meatus with a single antiseptic wipe. If a patient has not voided in the 8 hours following the removal of an indwelling catheter or has voided less than 240 mL, a nurse should. >> Go To The Portal
The Nursing assistant notices the patient's urine is an amber color and cloudy. The patient is complaining of frequency, dysuria, and burning sensation when voiding. The nursing assistant suspects the patient may have the following:
(B) The nursing assistant should tell residents' families about episodes of incontinence so they can encourage residents to do better. (C) The nursing assistant should change wet or soiled linens or incontinence briefs
The nurse notices that the client becomes more agitated, restless, and confused in the late afternoon and evening. Which condition is the client demonstrating? The nursing assistant is helping a person with dementia with activities of daily living (ADLs).
While assisting the resident to the bathroom, the nursing assistant notices that the resident is wheezing and that the resident's breathing is much faster than normal. What action should the nursing assistant prioritize at the time?
Follow these steps two times a day to keep your catheter clean and free of germs that can cause infection: Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails. Change the warm water in your container if you are using a container and not a sink.
Reviewed by Dr Helen Huins. This form is to: 1) Record the times you pass urine, 2) Record the amount of urine you pass on each occasion and 3) Record the times you leak urine (are incontinent). Tick (to the nearest hour) each time you go to the toilet to pass urine.
Cystometry is a test used to look for problems with the filling and emptying of the bladder. The bladder is part of the urinary tract. It's a hollow muscular organ that relaxes and expands to store urine. Cystometry measures the amount of urine in the bladder.
Which effect of aging should the nurse consider when performing a urinary assessment? Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.
Physical Examination The abdominal examination looks for a distended bladder, which may indicate problems with incomplete bladder emptying. The pelvic examination (similar to when having a Pap smear) assesses: Leakage with “stress test” or cough test i.e. coughing and straining to look for stress incontinence.
The most frequently used nursing interventions provided were counselling related to fluid and caffeine intake, pelvic muscle exercises (for stress incontinence and to suppress urinary urgency) and bladder training, using regular timed voiding. Over 90% of treatment subjects received all of these interventions.
Cystometry is done to: Find the cause of problems with the bladder or the muscle that holds urine in the bladder (bladder sphincter). Problems in one or both of these areas may cause uncontrolled urine leakage, an urgent feeling that you have to urinate, or a weak urine stream.
Before the test, you will be asked to empty your bladder as much as you can. A small soft tube (called a catheter) is inserted into the urethra until it reaches your bladder. The catheter allows the bladder to be emptied completely. It is also used to measure the amount of urine remaining in the bladder after you go.
During Your Cystometry A flexible, thin plastic catheter is then slowly inserted through the urethra (the tube that carries urine out of the bladder) and into your bladder. Measurements will then be taken of how much, if any, urine remains in your bladder and bladder pressure.
These include adequate intake of fiber and fluids, routine exercise, and appropriate use of laxative agents. It is particularly important for women to prevent chronic constipation because straining at stool is a risk factor for stress incontinence due to loss of normal pelvic muscle tone.
Bowel Elimination Assessment Subjective assessment of the bowel system includes asking about the patient's normal bowel pattern, the date of the last bowel movement, characteristics of the stool, and if any changes have occurred recently in stool characteristics or pattern.
Normal urine output is 1-2 ml/kg/hr. To determine the urine output of your patient, you need to know their weight, the amount of urine produced, and the amount of time it took them to produce that urine. Urine output should be measured at least every four hours if possible.
To calculate the rate of urine output, divide the volume of urine produced by the number of hours that have elapsed since the bag/chamber was last emptied (e.g. 80ml over 2 hours = 40ml/hour).
0:231:41The candidate measures the amount of urine at eye level with the container on a flat surface. AfterMoreThe candidate measures the amount of urine at eye level with the container on a flat surface. After measuring urine the contents are emptied into the toilet.
Record the amount of infusion or transfusions and other intakes at fluid intake column. Record any output such as urine, watery stool, vomitus at output column. Balancing the fluid intake and output chart, depends on the hospital protocol. Find fluid balance by subtracting output from intake.
2:345:04We can see that it is 600 cc's if it were between the 600 and the next line which is 625 had itMoreWe can see that it is 600 cc's if it were between the 600 and the next line which is 625 had it fallen in between I would go up to the 25 mark and that would be 625.
ANS: B The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of...
ANS: B Acute pain is the only NANDA-I–approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and s...
ANS: C The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process o...
ANS: B The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate...
ANS: A Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment,...
ANS: D Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is “Complains of moderate discomfort,”...
ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with devel...
ANS: D The patient’s desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human respon...
ANS: A The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient’s resp...
The patient experienced prerenal failure because the cause was prior to the kidneys rather than damage to the kidneys itself or urinary structures. DIF: Applying REF: p. 1077. The nurse is caring for a patient with diabetes insipidus.
Intermittent catheters need not be secured to the patient's leg because they will be removed after the bladder is drained. DIF: Understanding REF: pp. 1096-1102. The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties.
ANS: A. A Coudé catheter is used when there is narrowing or constriction of the urethra, making insertion of a regular indwelling catheter difficult. The Coudé catheter has a special tip on the end that is designed to facilitate insertion of the catheter through the narrowed urethra caused by BPH.
tract. Urine that smells of nail polish remover contains ketones from high blood sugar. Urine that is cloudy with a foul odor and positive for nitrites is most likely due to urinary tract infection.
The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder.
PO fluid intake should be encouraged to facilitate excretion of the contrast dye. Burning or pain with urination should not occur after IVP testing because there is no instrumentation of the urinary tract. Assessment of allergies must be done before the IVP is done because iodine-based contrast is used.
ANS: A. The presence of an indwelling urinary catheter puts the patient at high risk for urinary tract infection, and this is the highest priority diagnosis for the patient. Disturbed body image is not as important as the risk of infection. Risk for contamination does not relate to spillage of urine on clothing.
The charge nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? a. Nursing diagnosis.
The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient’s chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement.
A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient’s needs.
After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.
The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate.
Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis.
A health promotion diagnosis is a clinical judgment of a patient’s motivation and desire to enhance well-being and does not require a current level of wellness. 9. 9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
By definition, diarrhea means that a patient is having frequent stools; therefore, asking about the number of bowel movements is most appropriate. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate.
Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (short ness of breath) and a diagnosis of asthma.
The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.) A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis.
A. (The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate.
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet.
(The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address.
Diagnostic labeling is simply the name of the diagnosis.) A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture.
The task that is most likely beyond the scope of a nursing assistant is: inserting an indwelling catheter. The nursing assistant is emptying the foley catheter bag, and notices the urine to have a presence of blood in the urine, This abnormal finding would be called: Hematuria.
The most significant difference between a urine specimen for routine urinalysis and a midstream urine specimen is: collection of a midstream urine specimen is in a sterile container, but collecting for a routine urinalysis is in a clean container. The nursing assistant positions a standard bedpan:
A general practitioner. To promote understanding for a patient or resident who appears to be experiencing difficulty understanding, the nursing assistant should: Noticing and reporting observations of changes in a client's or resident's condition. The nursing assistant has been charged with abuse of a client.
The nursing assistant, when disposing of the contents of the bedpan, notes the stool is black and has a tar-like appearance. The next action of the nursing assistant is to: ask the nurse to assess the contents of the bedpan.
Wear gloves when shaving a man because of the risk of contacting blood. The nursing assistant works mainly night shift and is diligent in maintaining an environment which will encourage proper sleeping for the residents.
A male resident is unable to get out of bed and must use a bedpan. for a bowel movement. The Nursing assistant notices the patient's urine is an amber color and cloudy. The patient is complaining of frequency, dysuria, and burning sensation when voiding.
The skin is dragged in a direction opposite that of the underlying tissues and muscles injuring the blood vessels and skin, starting the process of skin breakdown, this is known as: Shearing. The client has a wound infection and has been placed on Contact Precautions. The nursing assistant is allergic to latex.
CNA Practice Test 1 (50 Questions Answers) The exam that follows simulates the National Standards exam for certified nursing assistants. If you are required to take a written exam in order to be certified, the exam you take is likely to be very much like this one. This exam has 50 multiple-choice questions covering the range of duties ...
The Foley bag must be kept lower than the patient’s bladder so that. Raising the bag above the bladder level can lead to backflow of the urine, with its bacteria, into the bladder. 43. When assisting a nurse to irrigate a patient’s bladder, you notice that the nurse has contaminated the sterile field.
Raising the bag above the bladder level can lead to backflow of the urine, with its bacteria, into the bladder. 43. When assisting a nurse to irrigate a patient’s bladder, you notice that the nurse has contaminated the sterile field. You should.