%PDF-1.7 % "It might help me to listen to music while I'm lying in bed.". As previously mentioned, a number of factors impact on the client, their preferences and their choices in terms of the kinds of foods that they want to eat and in terms of the quantity of food that they want to consume. Which of the following statements should the nurse make? A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. dehydration and fluid overload a graduated container clearly marked with: ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music In which of the following situations does the nurse demonstrate the ethical principle of veracity? A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. After which of the following observations should the nurse remove the IV catheter? These modifications must be explored and discussed with the client; alternatives should be offered and discussed and the closer these alternative options are to the client's preferences, the greater the client's adherence to their dietary plan will be. Fluid excesses are the net result of fluid gains minus fluid losses. RegisteredNursing.org Staff Writers | Updated/Verified: Feb 10, 2023. -Consider switching the tube to the other naris Check the cord routinely for frays or tearing. -Implement a bladder training program. Major differences in I & O to the client ' s physician site is preferable for injections. Consider purchasing a generator for power backup. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? Which of the following tasks should the nurse assign to an assistive personnel (AP)? ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) Business PLAN OF Pusong Lumpia; QSO 321 1-3: Triple Bottom Line Industry Comparison; Newest. -turn on music to comfort them, Integumentary and Peripheral Vascular Systems: Findings to Report From a Skin Assessment, Older Adults (65 Years and Older): Identify Expected Changes in Development, Older Adults (65 Years and Older): Teaching About Manifestations of Delirium, -infection (especially UTI-first manifestation!!!) Explain. For example, the client's body mass index (BMI) and the "ideal" bodily weight can be calculated using relatively simple mathematics. A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. A nurse is assessing a client who reports increased pain following physical therapy. The parents have refused the treatment due to religious beliefs. -Monitor patency of catheter. hbbd```b``z "s@$U0[D2'`LIv0yL $[9-gt&F7 !30}` $&w -back channeling : tell me more! For which of the following practices should the nurse intervene? Clients can be instructed to count calories by weighing the food that will be eaten and then multiply this weight in grams by the number of calories per gram. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. The patient calculating a patient ' s daily intake will require you to record all fluids that go the! -ROM exercises "We need to document the exact mediation you were taking because you might be allergic to it.". Some of the terms and terminology relating to hydration and the client's hydration status that you should be familiar with for your NCLEX-RN examination include these below. -When hearing aids are not in use for an extended time, turn it off and remove the battery. Naso tubes, like the nasogastric and nasoduodenal tubes, are the preferred tube because their placement is noninvasive, however, naso tubes are contraindicated when the client has a poor gag reflex and when they have a swallowing disorder because any reflux can lead to aspiration. -footboards used to prevent foot drop!! Sign to alert medical personnel of I&O measurement. Greater than 7.5% in 3 months indicates a significant weight loss 6 -Exercise regularly. Obtain the pronouncement of death from the provider . The mathematical rule for calculating the client's BMI is: BMI = kg of body weight divided by height in meters squared. Diet (caffeine consumption before bed) Clinical decision point: Which of the following responses should the nurse make? A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. A parallel-plate capacitor with C=10FC=10 \mu \mathrm{F}C=10F is charged so as to contain 1.2J1.2 \mathrm{~J}1.2J of energy. 1.imbalance and report to HCP Some of these interactions are synergistic and others are antagonistic, that is these interactions can increase and potentiate the effects of the medication(s) and others neutralize and inhibit the therapeutic effects of the medication. Intake includes all liquids (oral fluids, food that liquefy at room . Requires ability to concentrate. What will the amplitude be if the total energy is doubled? A nurse enters a client's room ad finds her on the floor. Caluculate, Fluid intake from the tube feedings A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. These special diets, some of the indications for them, and the components of each are discussed below. Make sure two fingers can fit under the sleeves. The nurse opens the sterile field on a wet surface. *Chapter 32. or -Unplanned pregnancies -Cognitive-behavioral measures- changing the way a client perceives pain, and physical approaches to improve comfort. ".0t4pt$e(A0& C1d2c8d}RJ 8/iF30yLw #t Weight clients at the same time , same amount of linen and reset the scale to 0 if possible Which of the following foods should the nurse suggest that the client ass to his diet? Measure CT drainage by marking and recording Assess the client for orthostatic hypotension. -Heat to increase blood flow and to reduce stiffness -Go 30 mmHg above after sound disappears Monitor I&O for how long, and what is used for? -Note smallest line client can read correctly. How to calculate tube feedings: Parenteral fluids For example, if a package of frozen food like chicken nuggets states that there are 2500 calories per package and there are 3 servings in each package, each serving will have about 833 calories when a person eats 1/3 of the package of chicken nuggets. -To clean the ear mold, use mild soap and water while keeping the hearing aid dry. Urinary output is monitored and measured in terms of mLs or ccs for toilet trained children and adults, and, in terms of diaper weights or diaper counts for neonates and infants. 3. excessive perspiration. Active Learning Template, nursing skill on fluid imbalances net fluid intake. fluid restrictions, such as a low-sodium diet. Clients receiving these feedings should be placed in a 30 degree upright position to prevent aspiration at all times during continuous tube feedings and at this same angle for at least one hour after an intermittent tube feeding. Serial bodyweights are an accurate method of monitoring fluid status One of the most sensitive indicators of patient volume status changes is their bodyweight. Place a name tag on the body. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? Step 8. Wash the client's body . A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. hb```, eagGHm blue line trax schedule; selena gomez makeup ulta; george m whitesides net worth; Media. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! -Use lowest setting that allowed hearing without feedback . Calculating a patient' s net fluid intake requires nurses to measure, record, and calculate a patients intake and output of liquids. A urinary output of less than 30 mLs or ccs per hour is considered abnormal. Liquids with meals, gelatin, custards, ice cream, popsicles, sherberts, ice chips Identify patients on what meds that influence fluid balance? -Assess for manifestations of breakdown. Which of the following instructions should the nurse provide to the client and his family? When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. calculating a clients net fluid intake ati remediation Focused learning review-fundamentals Flashcards | Quizlet 2003-2023 Chegg Inc. All rights reserved. 3.change in weight. Accuracy for I&O is critical and what will physicians use these findings for: prescription of medications and IV fluids. learn more TEST YOUR A & P KNOWLEDGE This online practice exam for Anatomy and Physiology is designed to test your general knowledge. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. All trademarks are the property of their respective trademark holders. Some medications interfere with the digestive process and others interact with some foods. Which of the following assessment findings should the nurse expect to confirm correct tube placement? The client's roommate reports that the client fell getting out of bed. -Interruption of pain pathways A nurse is caring for a client who does not speak the same language as the nurse. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. critical point today.edited vrais.docx - Critical Points Ankle pumps, foot circles, and knee flexion, Mobility and Immobility: Teaching About Reducing the Adverse Effects of Immobility, Nasogastric Intubation and Enteral Feedings: Unexpected Findings (ATI pg 334), -Excoriation of nares and stomach In addition to aspiration, some of the other complications associated with tube feedings include tube leakage, diarrhea, dehydration, nausea, vomiting, inadvertent improper placement or tube dislodgment, nasal irritation when a naso tube is used and infection at the insertion site when an ostomy tube is used for the enteral nutrition. -related to change in surroundings, Thorax, Heart, and Abdomen: Client Teaching About Breast Self-Examination. Record intake when: What do you do if one or more patient's in the same room? A nurse is teaching a client and his family how to care for the client's tracheostomy at home. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Alene Burke RN, MSN is a nationally recognized nursing educator. -active listening In addition to these calculations, the nurse must also be knowledgeable about what is and what is not a good body mass index or BMI. Which of the following findings should the nurse identify as a potential indication of abuse? A nurse is caring for a client who has a heart murmur. Nutrition ATI Remediation Flashcards | Quizlet Young adults at risk for: The residual volume of these feedings is aspirated, measured and recorded at least every 6 hours and the tube is flushed every 4 hours to maintain its patency. Which of the following actions should the nurse take? Fluid Imbalances - N/A - Nurs 210 - Studocu KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? Which of the following information should the nurse give to the client? Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators about the client's nutritional status. Infants and young children at risk for alterations in terms of fluid imbalances because of their relatively rapid respiratory rate which increases inpercernible fluid losses through the lungs, the child's relatively immature renal system, and a greater sensitivity to fluid losses such as those that occur with vomiting and diarrhea. Assessing the Client for Actual/Potential Specific Food and Medication Interactions, Considering Client Choices Regarding Meeting Nutritional Requirements and/or Maintaining Dietary Restrictions, Applying a Knowledge of Mathematics to the Client's Nutrition, Promoting the Client's Independence in Eating, Providing and Maintaining Special Diets Based on the Client's Diagnosis/Nutritional Needs and Cultural Considerations, Providing Nutritional Supplements as Needed, Providing Client Nutrition Through Continuous or Intermittent Tube Feedings, Evaluating the Side Effects of Client Tube Feedings and Intervening, as Needed, Evaluating the Client's Intake and Output and Intervening As Needed, Evaluating the Impact of Diseases and Illnesses on the Nutritional Status of a Client, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), Providing Information to the Client on Common Side Effects/Adverse Effects/Potential Interactions of Medications and Informing the Client When to Notify the Primary Health Care Provider, Non Pharmacological Comfort Interventions, Basic Care & Comfort Practice Test Questions, Assess client ability to eat (e.g., chew, swallow), Assess client for actual/potential specific food and medication interactions, Consider client choices regarding meeting nutritional requirements and/or maintaining dietary restrictions, including mention of specific food items, Monitor client hydration status (e.g., edema, signs and symptoms of dehydration), Apply knowledge of mathematics to client nutrition (e.g., body mass index [BMI]), Manage the client's nutritional intake (e.g., adjust diet, monitor height and weight), Promote the client's independence in eating, Provide/maintain special diets based on the client diagnosis/nutritional needs and cultural considerations (e.g., low sodium, high protein, calorie restrictions), Provide nutritional supplements as needed (e.g., high protein drinks), Provide client nutrition through continuous or intermittent tube feedings, Evaluate side effects of client tube feedings and intervene, as needed (e.g., diarrhea, dehydration), Evaluate client intake and output and intervene as needed, Evaluate the impact of disease/illness on nutritional status of a client, Personal beliefs about food and food intake, A client with poor dentition and misfitting dentures, A client who does not have the ability to swallow as the result of dysphagia which is a swallowing disorder that sometimes occurs among clients who are adversely affected from a cerebrovascular accident, A client with an anatomical stricture that can be present at birth, The client with side effects to cancer therapeutic radiation therapy, A client with a neurological deficit that affects the client's vagus nerve and/or the hypoglossal cranial nerve which are essential for swallowing and the prevention of dangerous and life threatening aspiration, 18.5 to 24.9 is considered a normal body weight.
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