-release scan button for reading, Young Adults (20 to 35 Years): Teaching Appropriate Health Promotion Guidelines (ATI pg 115). Similar to rectal temps! -Ankle pumps: point toes toward the head and then away from the head. 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. Instruct the patient or family members to call nurse or NAP to: 1. empty contents of urinal, urine hat, or commode each time patient uses it. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following actions should the nurse take first? -Cover opposite eye. Some of the assistive devices that can be used to accommodate for clients' weaknesses and to promote their independent eating include items like weighted plates, scoop dishes, food guards around the plate, assistive utensils, weighted and tip proof drinking glasses and cups. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? Measure and record all fluid intake. 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. -INSPECTION, AUSCULTATION, PERCUSSION, PALPATION Fluid losses occur as the result of vomiting, diarrhea, a high temperature, the presence of ketoacidosis, diuretic medications and other causes. I will be sure to remove my hearing aid before taking a shower.. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? 8 oz of ice chips. -ADLs- Bathing, grooming, dressing, toileting, ambulating, feeding(without swallowing precautions), positioning. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Like other basic human needs such as elimination, nutrition can be negatively impacted by a number of factors and forces such as diseases and disorders like anorexia, nausea, vomiting, anorexia, dysphagia and malabsorption, cultural and ethnical beliefs about nutrition and foods, personal preferences, level of development, lifestyle choices, economic restraints, psychological factors and disorders such as eating disorders, medications, and some treatments like radiation therapy and chemotherapy. Step 8. Which of the following actions should the nurse take? In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of nutrition and oral hydration in order to: Assess client ability to eat (e.g., chew, swallow) Assess client for actual/potential specific food and medication interactions. -Apply cuff 2.5 cm 1 in) above antecubital space Obtain the pronouncement of death from the provider . The signs and symptoms of mild to moderate dehydration include, among others, orthostatic hypotension, dizziness, constipation, headache, thirst, dry skin, dry mouth and oral membranes, and decreased urinary output. This includes oral intake, tube feedings, intravenous fluids, medications, total parenteral nutrition, lipids, blood pro View the full answer Transcribed image text: Assistive Personnel: Diet (caffeine consumption before bed) Save. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of nutrition and oral hydration in order to: Adequate nutrition consists of the ingestion and utilization of water, essential nutrients, vitamins and minerals to maintain and sustain health and wellness. Teach family members the rationale for the, importance of offering fluids regularly to, clients who are unable to meet their own needs, cognition, or other conditions such as impaired. A nurse enters a client's room ad finds her on the floor. Bolus enteral feedings are given using a large syringe and they are typically given up to 6 times a day over the course of about 15 minutes. 2. at the same time Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. -probing Enteral nutrition can be given on a continuous basis, on an intermittent basis, as a bolus, and also as supplementation in addition to oral feedings when the client is not getting enough oral feedings. -Heat to increase blood flow and to reduce stiffness Example: 67 oz = 2010 mL Miscellaneous: Tube feedings (include free water) IV and central line fluids (TPN, lipids, blood products, medication infusion) Step 11. -Periodontal disease due to poor oral hygiene A charge nurse is observing a newly licensed nurse prepare a sterile field. blue line trax schedule; selena gomez makeup ulta; george m whitesides net worth; Media. Calculate fluid intake for: Parenteral fluids blood components total parenteral nutrition solutions *Chapter 29, 30 and 13 Clinical decision point: Record intake when: As soon as you measure it for accuracy. Pharmacokinetics & Routes of Administration: Evaluating Client Understanding of Heparin Self-Administration Dosage Calculation: IV Infusion Rate of 0.9% Sodium Chloride REDUCTION OF RISK POTENTIAL Intravenous Therapy: Inserting a Peripheral IV for Older Adult Clients Fluid Imbalances: Evaluating the . * look at page 148, Health Promotion and Disease Prevention: Stages of Health Behavior Change, Hygiene: Bathing a Client Who Has Dementia, -Let them know what you are doing. A nurse is teaching a client whose left leg is in a cast about using crutches. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Women, in contrast to male clients, are at greater risk for alterations in terms of bodily fluids because they tend to have more fat, which contains less fluid, than muscle which contains more bodily fluid. Which of the following actions should the nurse take? 100 mL of ice chips = 50 mL of water, Step 10 b. What will the amplitude be if the total energy is doubled? When working with the client through an interpreter, which of the following actions should the nurse take? Which of the following signatures may the nurse legally witness? Calculate and chart extra fluid with meals, Before the client is reading for preop the client, Not assessing the patient output and intake can, cause potentially serious problems such as. The client may simply ask the nurse for a turkey sandwich, something that can be given to the client when it is available and it is not contraindicated according to the client's therapeutic diet. Collaborate with respiratory care for oxygen tx if needed. What do you do if one or more patient's in the same room? Identify the type of breath sounds. Thread the IV catheter so that the hub rests at the insertion site. -Keep skin clean and dry. When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur. Weight clients at the same time , same amount of linen and reset the scale to 0 if possible Educate the client on the importance calculating fluid intake. -Verify suction equipment functions properly, Nutrition and Oral Hydration: Advancing to a Full Liquid Diet (ATI pg 223), Clear liquids plus liquid dairy products, all juices. At times, abdominal cramping and diarrhea can be prevented by slowing down the rate of the feeding. A nurse is caring for a child who has a prescription for a blood transfusion. View "When descending stairs, I will first shift my weight to my right leg.". The A, B, C and Ds of nutritional assessment include: Some of the factors that impact on the client's nutrition, their nutritional status and their ability to eat include: Swallowing disorders, chewing disorders and poor dentition are factors that can impede the client's mechanical ability to eat. -Help with personal hygiene needs or a back rub prior to sleep to increase comfort. Which of the following statements should the nurse identify as an indication that the client understands the teaching? These special diets, some of the indications for them, and the components of each are discussed below. Clients must be encouraged to drink these supplements as ordered and the client's flavor preference should also be considered and provided to the client whenever possible. -Go 30 mmHg above after sound disappears Emotional or mental stress Which of the following actions should the nurse take? A problem is an ethical dilemma when: A review scientific data is not enough to solve it. Identify patients on what meds that influence fluid balance? 253), -Use soap and water at insertion site. 220), -position client using corrective devices (ex. -DO NOT DELEGATE CHECKING FOR ORTHOSTATIC HYPOTENSION A nurse is preparing to administer enoxaparin subcutaneously to a client. The provider briefly discusses treatment options and leaves the client's room. A nurse is caring for a client who does not speak the same language as the nurse. Solid output is measured in terms of the number of bowel movements per day; liquid stools and diarrhea are measured in terms of mLs or ccs. Specific risk factors associated with fluid excesses include poor renal functioning, medications like corticosteroids, Cushing's syndrome, excessive sodium intake, heart failure, hepatic failure and excessive oral and/or intravenous fluids. The family member washed out the feeding bag with warm water once every 24 hours. `record I&O The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. 399 0 obj <>stream -Have client lie supine with arms at both sides and knees slightly bent. Apply clean gloves. Step 3. -Note smallest line client can read correctly. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Some of the side effects and complications associated with tube feedings, their prevention and their interventions are discussed below. This interactive, online tutorial was designed to break down and simplify one of the most difficult subjects in nursing school, Pharmacology. A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Which of the following actions should the nurse take? Medications have a great impact on the client's nutritional status. a graduated container clearly marked with: -Release no faster than 2-3 mmHg per second -knee flexion: flex and extend the legs at the knees How to calculate tube feedings: Parenteral fluids In addition to measuring the client's intake and output, the nurse monitors the client for any complications, checks the incisional site relating to any signs and symptoms of irritation or infection for internally placed tubes, secures the tube to prevent inadvertent dislodgement or malpositioning, cleans the nostril and tube using a benzoin swab stick, applies a water soluble jelly just inside the nostril to prevent dryness and soreness, provides frequent mouth care, and replaces the securing tape as often as necessary. Step 13 e. Gastric drainage/ Larger drainage pouches by: opening clamp and pouring into a graduated cup with a 240 mL capacity.`. The nurse is preparing to auscultate the pulmonary valve. A 16-year-old client who is married. ***Relaxation- meditation, yoga, and pregressive muscle relaxation. 38% to 47% for Females 10% or less of total calories should come from saturated fat sources) (Nutrition ATI: Chapter 1; Page 5) Recommended Foods for Managing Diarrhea -make sure it isn't kinked (what to do FIRST) Measure the client's BP after the nurse administers an antihypertensive medication. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? You'll get a detailed solution from a subject matter expert that helps you learn core concepts. The body mass index is calculated using the client's bodily weight in kg and the height of the client in terms of meters. The calculations for both of these variables were discussed above. Which of the following are ionic compound, and which are covalent compounds: RbCl,PF5,BrF3\mathrm{RbCl}, \mathrm{PF}_5, \mathrm{BrF}_3RbCl,PF5,BrF3. 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. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 1. time on collection chamber at specified intervals. In addition to planning a diet with the client to increase or decrease their body weight, the client's weight and body mass index should be monitored on a regular basis. 1. Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the body. -Stand 20 feet away. Ask the client's family members if they would like to view the body . -Divide abdomen in four quadrants in head. 2. vomiting A nurse is planning care for a client who has fluid overload. Active Learning Template, nursing skill on fluid imbalances net fluid intake. Bowel Elimination: Assisting a Client to Use a Fracture Pan, We use fracture pans for supine patients and for patients in body casts or leg casts.For client using a fracture pan, raise the head of the bed to 30 DEGREES (semi-Fowler's : 30-45 degrees), Complementary and Alternative Therapies: Contraindications for Receiving Acupuncture, Complementary and Alternative Therapies: Contraindications for the Use of Magnet Therapy, Complementary and Alternative Therapies: Identifying Potential Medication Interactions With Ginkgo Biloba, Ergonomic Principles: Safely Transferring a Client From the Bed to a Chair, -Use two or more people to transfer patient, Fluid Imbalances: Assessment Findings of Extracellular Fluid Volume Deficit (CP card #164). These client choices and preferences become quite challenging indeed when the client has a dietary restriction. -Substance abuse Have patient and family monitor what to the nurse: 1. incontinence Discharge Care edema, reduced cardiac output, and hypotension. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. how to delete saved games on sims 4 pc; magaddino memorial chapel haunted; Which of the following findings should the nurse expect? endstream endobj 350 0 obj <>/Metadata 13 0 R/Pages 347 0 R/StructTreeRoot 17 0 R/Type/Catalog/ViewerPreferences 369 0 R>> endobj 351 0 obj <>/MediaBox[0 0 612 792]/Parent 347 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 352 0 obj <>stream A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following responses should the nurse make? "We need to document the exact mediation you were taking because you might be allergic to it.". Intake includes all liquids (oral fluids, food that liquefy at room . After securing a safe environment, which of the following actions should the nurse take next? What is the normal Hct range for Females and Males? Greater than 7.5% in 3 months indicates a significant weight loss 6 All diets, including these special diets, must be modified according to the client's cultural preferences, religious beliefs and personal preferences to the greatest extent possible. A nurse working in the Emergency Department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following instructions should the nurse provide to the client and his family? 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. Patient weight changes approximate a gold standard to determine fluid status. -Cutaneous stimulation- transcutaneous electrical nerve stimulation(TENS) heat, cold, therapeutic touch, and massage. The signs and symptoms of severe dehydration include, among others, oliguria, anuria, renal failure, hypotension, tachycardia, tachypnea, sunken eyes, poor skin turgor, confusion, fluid and electrolyte imbalances, fever, delirium, confusion, and unconsciousness. 384 Documents. 1.swallowing %PDF-1.7 % -pain A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Administer the medication with the needle at a 45 degree angle. -active listening 3. used only for the patient indicated. The client requests information about advance directives. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. **SEE other sets for diets, Nutrition and Oral Hydration: Calculating Fluid Intake (ATI pg 223), -Intake includes all liquids: oral fluids, foods that liquify at room temp, IV fluids, IV flushes, IV medications, enteral feedings, fluid installations, catheter irrigants, tube irrigants, Pain Management: Determining effectiveness of Nonpharmacological Pain Relief Measures (ATI pg 238). Fluid Imbalances: Calculating a Client's Net Fluid Intake Include volume intake to get a net fluid balance calculation as well (assuming no other fluid losses) Weight, total urine output, hours, and fluid intake. According to the U.S. Department of Health and Human Services, a body mass index of: As with all activities of daily living, nurses and other members of the health care team must promote and facilitate the client's highest degree of independence that is possible in terms of their eating, as based on the client, their abilities and their weaknesses. 2. bed location Unformatted text preview: To be significant and to suggest fluid depletion, a drop of at least 15mmHg will be noted in the systolic pressure, with a drop of 10mmHg in the diastolic pressure. %%EOF For example, the client's body mass index (BMI) and the "ideal" bodily weight can be calculated using relatively simple mathematics. Over which of the following locations should the nurse place the bell of the stethoscope? Which of the following actions should the nurse include? -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!!!) Analytical Reading Activity Jefferson and Locke, Analytical Reading Activity 10th Amendment, CCNA 1 v7.0 Final Exam Answers Full - Introduction to Networks, The Deep Dive Answers - jdjbcBS JSb vjbszbv, 1-2 Module One Activity Project topic exploration, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Info More info. Fluid Imbalances: Calculating a Client's Net Fluid Intake Include volume intake to get a net fluid balance calculation as well (assuming no other fluid losses) Weight, total urine output, hours, and fluid intake Hygiene: Providing Instruction About Foot Care (CP card #97) -inspect feet daily -use LUKEWARM water -dry feet thoroughly "We will apply oxygen through a tube in your nose.". 368 0 obj <>/Filter/FlateDecode/ID[<6E09610638DE554D84C38FD9E764D804>]/Index[349 51]/Info 348 0 R/Length 98/Prev 150032/Root 350 0 R/Size 400/Type/XRef/W[1 3 1]>>stream Caluculate, Fluid intake from the tube feedings The doctor's order for these nutritional supplements states the name of the specific nutritional supplement and the number of cans per day. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. Which of the following responses should the nurse provide? Explain to the patient and family: Step 10. aMeasure and Record all fluid intake: -ROM exercises RegisteredNursing.org does not guarantee the accuracy or results of any of this information. Nursing Interventions There are five different types of calculations; solid oral medication, liquid oral medication, injectable medication, injectable, correct doses by weight, and IV infusion rates. Swelling and coolness are observed at the IV site. For which of the following clients should the nurse consult the provider before using this complementary therapy? Some facilities include pureed vegetables in a full liquid diet Lab Report #11 - I earned an A in this lab class. Which of the following statements should the nurse make? A nurse is caring for a client who is postoperative. Which of the following findings should the nurse expect? A nurse is admitting a client who is having an exacerbation of heart failure. -Exercise regularly. A nurse is caring for a client who has a heart murmur. The nurse opens the sterile field on a wet surface. There are a number of therapeutic special diets that are for clients as based on their health care problem and diagnosis. Inform patient and family that foley cath drainage bag, and wound, gastric or CT drainage are: closely monitored , measured and recorded and who is responsible. Recorded as 50% of measured volume -clarifying A nurse is assessing a client who reports increased pain following physical therapy. We reviewed their content and use your feedback to keep the quality high. Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? Judging from its unit W/mK,W/m \cdot K,W/mK, can we define thermal conductivity of a material as the rate of heat transfer through the material per unit thickness per unit temperature difference? This is often the case when a client is recovering from a physical disease and disorder, particularly when this disease or disorder is accompanied with nausea, vomiting, and/or anorexia. Ex. Clients with poor dentition and missing teeth can be assisted by a dental professional, the nurse and the dietitian in terms of properly fitting dentures and, perhaps, a special diet that includes pureed foods and liquids that are thickened to the consistency of honey so that they can be swallowed safely and without aspiration when the client is adversely affected with a swallowing disorder. What is the normal urine specimen gravity? 1.Maintaining standard precautions related to body fluids. In which of the following situations does the nurse demonstrate the ethical principle of veracity? Step 2. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following actions should the nurse add to the client's plan of care? a "hat" into patient voids or a graduated container. -Comfortable environment. 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. Which of the following actions should the charge nurse identify as contaminating the sterile field? A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. -Apply protective barrier creams. What is the nurse responsible for in monitoring I&O? Which of the following precautions should the nurse plan for this client? pillow, foot boots, trochanter rolls, splints, wedge pillows), Mobility and Immobility: Evaluating a Client's Use of a Walker (CP card #107), Mobility and Immobility: Preventing a Plantar Flexion Contracture**. Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. 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. To convert oz to mL, simply multiply the amount of oz by 30. -Routine tasks- bed making, specimen collection, I&O, Vital signs (Stable Clients). hypotension vs. hypertension B !$f%+1:H/ -Consider switching the tube to the other naris 127, Head and Neck: Assessing Visual Acuity Using a Snellen Chart (ATI pg 146), -Use to screen for myopia. Some measurable outputs are urinary elimination, residual that is aspirated when the client is getting a tube feeding, wound drainage, ostomy output, and vomitus. Which of the following pieces of information is the priority for the nurse to provide? KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music A urinary output of less than 30 mLs or ccs per hour is considered abnormal. Which of the following actions should the nurse take? When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. For example, the client is assessed using the A, B, C and Ds of a nutritional assessment in addition to the use of some standardized tools such as the Patient Generated Subjective Global Assessment and the Nutrition Screening Inventory. Regulate oxygen via nasal cannula at a flow rate no more than 6l/min. All trademarks are the property of their respective trademark holders. A block oscillating on a spring has an amplitude of 20 cm. Step 12. Nutrition and oral hydration Basic concept template (calculating fluid and intake) Expert Answer 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 me Admissions, Transfers, and Discharge: Dispossession of Valuables, Admissions, Transfers, and Discharge: Essential Information in a Hand-Off Report, Client Education: Discharge Planning for a Client Who Has Diabetes Mellitus, Critical Thinking and Clinical Judgment: Caring for a Client Who Has Nausea, Critical Thinking and Clinical Judgment: Prioritizing Client Care, Cultural and Spiritual Nursing Care: Communicating With a Client Who Speaks a Different Language Than the Nurse About Informed Consent, Cultural and Spiritual Nursing Care: Discharge Teaching for a Client Who Does Not Speak the same language as the nurse, Cultural and Spiritual Nursing Care: Effective Communication When Caring for a Client Who Speaks a Different Language Than the Nurse, Delegation and Supervision: Assigning Tasks to Assistive Personnel (ATI pg.