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NURS 142 Final Exam - Questions With Perfect Solutions
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NURS 142 Final Exam - Questions With Perfect Solutions
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NURS 142 Final Exam - Questions With PerfectSolutions
Monitoring fluid balance Right Ans - Daily weights- loss or gain
Vital sings- significant changes
Intake and output
Oral intake Right Ans - 1200-1500ml
food intake Right Ans - 1000ml
food metabolism Right Ans - 200
total intake Right Ans - 2400-2700ml
Urine output Right Ans - 1400-1500ml
feces output Right Ans - 100-200ml
skin lungs sweat output Right Ans - 900-1000ml
total output Right Ans - 2400-2700ml
How can illness upset intake and output homeostasis Right Ans - ex: a 24
hour urinary output of less than 500ml can indicate dehydration for an
average size healthy adult
Intake and output skill Right Ans - Intake and output is the measurement of
all fluids entering and leaving the body
intake components Right Ans - oral fluids, ice chips, foods liquid at room
temp, tube feedings, parenteral fluids, irrigants
output components Right Ans - urine, emesis, diarrhea, tube drainage,
wound drainage
sensible fluid loss Right Ans - measurable output
,insensible fluid loss Right Ans - output that is immeasurable
Indications for I and O Right Ans - Fever, Diuretic Therapy, excessive
fluid/electrolyte loss, IV therapy, restricted fluid intake, edema, major
surgery, serious infections, renal disease, congestive heart failure, diabetes
risk factors for fluid imbalance Right Ans - prolonged vomiting, water
stools, inability to eat or drink due to illness
signs and symptoms of fluid imbalance Right Ans - sudden weight gain or
loss, decrease in urine volume, swollen ankles, dizziness, confusion
I and O equipment Right Ans - bedside intake and output sheet, graduated
measuring receptacle, bedpain, Hat for in toilet, urinal, bedside toilet, gloves
I and O key points Right Ans - measure at eye level, Physician order not
required, I and O totaled every 12 to 20 hours, 24 hour balance is calculated,
measure do not estimate
Life span considerations I and O: infant Right Ans - infant fontanels are
valuable indicators or fluid balance
diapers: compare weight of dry diaper to wet; infants dehydrate quickly in
comparison to children; children need to regenerate after exercise
True or false skin turgor is a valid indication for dehydration in older adults
Right Ans - false
true or false older adults have impaired thirst sensation Right Ans - true
one gram = ?ml Right Ans - one ml out output
Health definition Right Ans - the presence or absence of health
a state of being well and using every power the individual possesses to the
fullest extent (florence)
a state of complete physical mental and social well being and not merely the
absence of disease or infirmity (WHO)
Wellness Right Ans - a state of well being
focuses attention on the whole being of the individual
,7 components of wellness Right Ans - environmental, occupational,
intellectual, spiritual, physical, emotional,social
Well being Right Ans - a component of health
CDC: the presence of positive emotions and moods, absence of negative
emotions, satisfaction with life, fulfillment and positive functioning
illness Right Ans - a highly personal state in which the individuals physical,
emotional, intellectual, social, developmental, or spiritual functioning is not
diminished
NOT synonymous with disease
may or may not be related to disease
Infection (the concept of tissue integrity) Right Ans - microorganisms grow
on the skin
Mobility (the concept of tissue integrity) Right Ans - impaired mobility
leads to skin breakdown
Perfusion (the concept of tissue integrity) Right Ans - decreased blood flow
to tissues decreases oxygen and nutrient delivery causing damage
Self (the concept of tissue integrity) Right Ans - alterations in tissue
integrity can affect perceptions of self related to body image
Nursing interventions to promote integrity Right Ans - assist with hygiene
care, linen change, assess skin for redness and skin breakdown, wound care,
repositioning and comfort measures, educate patient on care of impaired skin,
assess skin for temp, color, sensation, pulses, encourage mobility, emotional
support
Priorities for hygiene care Right Ans - hands, oral, rectal, perineal, buttocks,
back
Making occupied and unoccupied bed Right Ans - body mechanics, patient
safety; use of side rails, roll linens inside out and hold it away from uniform,
place directly in hamper never on the floor, smooth out wrinkles
, Assessment Right Ans - tissue integrity, color of skin, temp of skin, oral
mucosa, tongue coating, poor hygiene, low fluid intake, effects of medication
Perfusion leg Right Ans - bathing the leg from the distal region to the thigh
promotes perfusion
Perfusion back Right Ans - promotes perfusion and reduces the risk for
loss of skin integrity
Perfusion buttocks Right Ans - buttocks care promotes perfusion and
reduces the risk for loss of skin integrity
Challenges to personal hygiene- male uncircumcised Right Ans - retract
foreskin and clean in the fold between the penis and foreskin
material collects and becomes a reservoir for infection
retracted skin must be reurned to natural position or edema and restriction of
the penis can occur
challenges to personal hygiene- dementia patient Right Ans - time the bath
based on patient mood, move slowly and let them know what youre going to
do, use distraction, stop if client becomes distressed, ask input from family
challenges to personal hygiene- unconcious patient Right Ans - place
patient on side; allows drainage of secretions or pooling to an area easily
accessed by suction
key points personal hygiene Right Ans - maintain privacy, comfort and
safety, proper body mechanics, allow patient to do what they can,
proper eye care Right Ans - use different corner of wash cloth for each eye;
wipe from inner to outer canthus
Peri-care for male and female Right Ans - use clean water and washcloth,
wash from cleanest to dirtiest, front to back
foley catheter care Right Ans - major source of healthcare assoociated
infection; should be used as briefly as possible, wash urinary meatus and
proximal catheter with soap and water dry gently
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