Which of the following statements should the nurse make? Which of the following actions should the nurse take? 2. fluids with medications, Step 10 c. Measure and record all fluid intake: 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 . Mobility and Immobility: Preventing Thrombus Formation (ATI pg. 3. used only for the patient indicated. A simpler method is to read food labels. Which of the following methods should the nurse use as a psychomotor approach to learning? -Stand 20 feet away. Insert the IV catheter without using a tourniquet. 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. Step 13. at end of each shift or a specific time like every 8 hours. -When hearing aids are not in use for an extended time, turn it off and remove the battery. 3. with the same scale -Have client lie supine with arms at both sides and knees slightly bent. Some of the terms and terminology relating to nutrition and hydration that you should be familiar with include those below. A nurse is calculating a client's fluid intake over the past 8 hr. Measure CT drainage by marking and recording 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. 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. 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. Each must have urine receptacles labeled with 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. Exercise (promotes sleep as long as it's TWO HOURS BEFORE bed) A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. 27) CNA. Intake and Output Practice Questions for Nurs, Pharm made easy 4.0: Introduction to Pharmaco, HCM 370 HCPCS pmt. Which of the following findings should the nurse identify as a potential indication of abuse? Which of the following responses should the nurse make? -Towel bath? -Evaluate both eyes. Explain to the patient and family: Step 10. aMeasure and Record all fluid intake: Identify the type of breath sounds. -Cold for inflammation "People in middle adulthood often find satisfaction in nurturing and guiding young people.". The relative severity of these nutritional status deficits must be assessed and all appropriate interventions must be incorporated into the client's plan of care, in collaboration with the client, family members, the dietitian and other members of the health care team. 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. The calculations for both of these variables were discussed above. For example, if the client will be eating a 14 grams of plain tuna fish, the number of calories can be calculated by multiplying 14 by 4 which would be 56 calories. Enteral tube feedings are delivered with a number of different tubes such as a nasointestinal tube that goes to the intestine through the nose, a nasogastric tube which is placed in the stomach through the nose, a nasojejunal tube that enters the jejunum of the small intestine through the nose, a nasoduodenal tube that enters the duodenum through the nose, a jejunostomy tube that is surgically placed directly into the jejunum of the small intestine, a gastrostomy tube that is surgically placed into the stomach directly and a percutaneous endoscopic gastrostomy (PEG) tube. Ask the client's family members if they would like to view the body . A nurse is reviewing the medical records of a client who has a pressure ulcer. A nurse is caring for a client who has a terminal illness and is approaching death. Leave 1-2 inches of catheter at end of penis, Urinary Elimination: Maintaining an Indwelling Urinary Catheter (ATI pg. -Read smallest line client is able to read. Assistive Personnel: Food drug interactions will be more fully discussed in the "Pharmacological and Parenteral Therapies" sections in the subtitled topic "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". Which of the following actions should the nurse take? . *Chapter 29, 30 and 13. How is this recorded? A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Edema is most often identified in the dependent extremities such as the feet and the legs; however, it can also become obvious with unusual abdominal distention and swelling. If using bed scale, use the same amount of linen each day and reset the scale to zero if possible. Pain Management: Suggesting Nonpharmacological Pain Relief for a Client, Rest and Sleep: Identifying Findings that Indicate Sleep Deprivation, Illness Which of the following actions should the charge nurse identify as contaminating the sterile field? Assess the client for orthostatic hypotension. Fluid excesses are the net result of fluid gains minus fluid losses. Apply intermittent suction when withdrawing the catheter. 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. Liquid medications, Count all liquid meds. %%EOF Which of the following actions should the nurse plan to take first? Make sure the client wears a mask when outside her room if there is construction in the area. 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. "We will apply oxygen through a tube in your nose.". All intake and output should . She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Associations task force on competency and education for the nursing team members. ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music *Chapter 32. -Consult provider about medicine to help sleep. 1. antacids -Release no faster than 2-3 mmHg per second blood components We reviewed their content and use your feedback to keep the quality high. -Use lowest setting that allowed hearing without feedback . This interactive, online tutorial was designed to break down and simplify one of the most difficult subjects in nursing school, Pharmacology. Current life events total parenteral nutrition solutions Which of the following assessment findings should the nurse expect to confirm correct tube placement? Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? The nurse opens the sterile field on a wet surface. Clinical decision point: a "hat" into patient voids or a graduated container. -Exercise regularly. 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. Wash the client's body . 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. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A nurse has just inserted an NG tube for a client. Talk directly to the client, instead of the interpreter, when speaking. Place a client who has tuberculosis in a room with negative-pressure airflow. A pH > 6 indicates that the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. 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. Collaborate with respiratory care for oxygen tx if needed. -Ask the client to urinate before the abdominal exam. -probing *****AVOID: crossing legs, sitting for long periods, wearing restrictive clothing on the lower extremities, putting pillow behind the knee, massaging legs A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. Lastly, clients who are febrile and clients who are exposed to prolonged hot environmental temperatures will lose bodily fluids as the result of sweating and these unpercernable fluid losses. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Course: NR 324 ADULT HEALTH. SEE Basic Care & Comfort Practice Test Questions. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the body. For example, a client with a chewing disorder, such as may occur secondary to damage to the trigeminal nerve which is the cranial nerve that controls the muscle of chewing, may have impaired nutrition in the same manner that these clients are at risk: Clients with a swallowing disorder are often assessed and treated for this disorder with the collaborative efforts of the speech and language therapist, the dietitian, the nurse and other members of the health care team. Administer the medication with the needle at a 45 degree angle. Lab Report #11 - I earned an A in this lab class. -while awake perform ROM exercises. BUT do not use continuously. -Cover opposite eye. -Apply water soluble lubricant to the nares as necessary The mathematical rule for calculating this ideal weight for males and females of small, medium and large body build are: Some clients need management in terms of weight reduction and others may need the assistance of the nurse and other health care providers, such as a registered dietitian, in order to gain weight. -Heat to increase blood flow and to reduce stiffness Calculate and chart extra fluid with meals, including juice, soup, ice cream and sherbet, gelatin, water on trays.Before the client is reading for preop the client needs to be NPO to prevent aspiration Not assessing the patient output and intake can cause potentially serious problems such as edema, reduced cardiac output, and hypotension. Although more clients should reduce their weight, there are some clients that have to be encouraged to gain weight. The parents have refused the treatment due to religious beliefs. Example: 67 oz = 2010 mL Miscellaneous: Tube feedings (include free water) IV and central line fluids (TPN, lipids, blood products, medication infusion) The assessment of the client's nutritional status is done with a number of subjective and objective data that is collected and analyzed. These clients should have attractive and preferred food preferences and, at times, they may need dietary supplements and medications to stimulate their appetite. The family member providing the feedings reports that the client has begun to have diarrhea. Edema is a sign of fluid excesses because edema occurs as the result of increases in terms of capillary permeability, decreases in terms of the osmotic pressure of the serum and increased capillary pressure. -If they get frustrated, stop and come back Adequate nutrition is dependent on the client's ability to eat, chew and swallow. 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. Some facilities include pureed vegetables in a full liquid diet 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. A nurse is preparing to administer enoxaparin subcutaneously to a client. Fatigue Home / NCLEX-RN Exam / Nutrition and Oral Hydration: NCLEX-RN. learn more TEST YOUR A & P KNOWLEDGE This online practice exam for Anatomy and Physiology is designed to test your general knowledge. -Foot circles: rotate the feet in circles at the ankles -ADLs- Bathing, grooming, dressing, toileting, ambulating, feeding(without swallowing precautions), positioning. Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators about the client's nutritional status. -release scan button for reading, Young Adults (20 to 35 Years): Teaching Appropriate Health Promotion Guidelines (ATI pg 115). 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Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. -pregnant or postmenopausal: perform BSE on the same day of each month!! such as Similarly, a client who will be eating 100 grams of a carbohydrate could calculate the number of calories by multiplying 100 by 4 which is 400 calories. "We can talk about advance directives, and I can also give you some brochures about them.". 1. time on collection chamber at specified intervals. Marie Wegener - DSDS-Gewinnerin 2018 . From a legal perspective, which of the following actions should the nurse take next? In combination, these forces push fluids into the interstitial spaces. 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. A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Measure and record all fluid intake. 3. mobility. Many times test questions will give you the amount in ounces (oz), but we record intake and output in milliliters (mL). learn more ATI Nursing Blog The aging population as well as Infants and young children are at greatest risk for fluid imbalances and the results of these imbalances. -Keep replacement batteries. -Acupuncture and acupressure- stimulating subcutaneous tissues at specific points using needles or the digits. Step 2. -Divide abdomen in four quadrants in head. Recorded as 50% of measured volume Step 12. -Routine tasks- bed making, specimen collection, I&O, Vital signs (Stable Clients). Which of the following actions should the nurse add to the client's plan of care? At times, abdominal cramping and diarrhea can be prevented by slowing down the rate of the feeding. What is the nurse responsible for in monitoring I&O? edema, reduced cardiac output, and hypotension. Educate the client on the importance calculating fluid intake. "We need to document the exact mediation you were taking because you might be allergic to it.". "I am available to talk if you should change your mind.". A nurse is caring for a group of clients on a medical-surgical unit. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following foods should the nurse suggest that the client ass to his diet? Swelling and coolness are observed at the IV site. -related to change in surroundings, Thorax, Heart, and Abdomen: Client Teaching About Breast Self-Examination. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A nurse is caring for a group of clients. What are we responsible for when monitoring I&O. -clarifying Many people on a weight reduction diet or a diet to increase their weight are based on calories counts. requires a prescription Ethical Responsibilities: Responding to a Client's Need for Information About Treatment, Grief, Loss, and Palliative Care: Responding to a Client Who Has a Terminal Illness and Wants to Discontinue Care, Information Technology: Action to Take When Receiving a Telephone Prescription, Information Technology: Commonly Used Abbreviations, Information Technology: Documenting in a Client's Medical Record, Information Technology: Identifying Proper Documentation, Information Technology: Information to Include in a Change-of-Shift Report, Information Technology: Maintaining Confidentiality, Information Technology: Receiving a Telephone Prescription, Legal Responsibilities: Identifying an Intentional Tort, Legal Responsibilities: Identifying Negligence, Legal Responsibilities: Identifying Resources for 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Following a Diagnosis of Cancer, Therapeutic Communication: Providing Psychosocial Support, Therapeutic Communication: Responding to Client Concerns Prior to Surgery, Airway Management: Collecting a Sputum Specimen, Bowel Elimination: Discharge Teaching About Ostomy Care, Complementary and Alternative Therapies: Evaluating Appropriate Use of Herbal Supplements, Diabetes Mellitus Management: Identifying a Manifestation of Hyperglycemia, Electrolyte Imbalances: Laboratory Values to Report, Gastrointestinal Diagnostic Procedures: Education Regarding Alanine Aminotransferase (ALT) Testing, Hygiene: Providing Oral Care for a Client Who Is Unconscious, Hygiene: Teaching a Client Who Has Type 2 Diabetes Mellitus About Foot Care, Intravenous Therapy: Actions to Take for Fluid Overload, Nasogastric Intubation and Enteral Feedings: Administering an Enteral Feeding Through a Gastrostomy Tube, Nasogastric Intubation and Enteral Feedings: Preparing to Administer Feedings, Nasogastric Intubation and 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Asepsis: Preparing a Sterile Field, Nursing Process: Priority Action Following a Missed Provider Prescription, Safe Medication Administration and Error Reduction: Client Identifiers, Chapter 6. pg.162-164 Monitoring Intake and O, Virtual Challenge: Timothy Lee (head-to-toe), Nursing 110 Exam 1 - Diagnostic testing/Lab v, Julie S Snyder, Linda Lilley, Shelly Collins. A 16-year-old client who is married. It involves a conflict between two moral imperatives. Over which of the following locations should the nurse place the bell of the stethoscope? Measure with a graduated container. 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. Because of space constraints, it's not comprehensive. Which of the following actions should the nurse take? Save. -ROM exercises A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Calculating a patient' s net fluid intake requires nurses to measure, record, and calculate a patients intake and output of liquids. A charge nurse is observing a newly licensed nurse prepare a sterile field. PLEASE NOTE: The contents of this website are for informational purposes only. The client's respirations are noisy from secretions in her airway and she is short of breath. Remove tubes and indwelling lines . Use a communication board to ask what the client wants for lunch. CHECK CIRCULATION EVERY 3 HRS?? University: Chamberlain University. Step 11. Nurses assess edema in terms of its location and severity. Have patient and family monitor what to the nurse: 1. incontinence Which of the following findings should the nurse expect? Diet (caffeine consumption before bed) dehydration and fluid overload -Apply protective barrier creams. 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 3.change in weight. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing.
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