The provider briefly discusses treatment options and leaves the client's room. -make sure it isn't kinked (what to do FIRST) 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. Recording the clients weight, total urine output, hours, and fluid intake Description of Skill Indications Outcomes/Evaluation CONSIDERATIONS Nursing Interventions (pre, intra, post) Potential Complications Client Education Nursing Interventions ACTIVE LEARNING TEMPLATES TherapeuTic procedure A9 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. The doctor is notified when the residual volume is excessive and when the tube is not patent or properly placed. Medications have a great impact on the client's nutritional status. endstream endobj startxref 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. 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. Fad diets and drastic weight reduction diets are not a successful way to lose and maintain a healthy weight; learning new eating habits is a successful plan for losing and maintaining a lower and healthier body weight for those clients who are overweight. 3. how to delete saved games on sims 4 pc; magaddino memorial chapel haunted; Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 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. 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. So, the BMI for a client weighing 75 kg who is 1.72 meters tall is calculated as follows: The ideal body weight is calculated using the client's height, weight and body frame size as classified as small, medium and large. or -Discomfort (look at ATI page 334 for more details) 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. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next? For example, clients who are taking an anticoagulant such as warfarin are advised to avoid vegetables that contain vitamin K because vitamin K is the antagonist of warfarin. -Go 30 mmHg above after sound disappears Sensory Perception: Evaluating a Client's Understanding of Hearing Aid Use (ATI pg. Solid intake is monitored and measured in terms of ounces; liquid intake is monitored and measured in terms of mLs or ccs. Which one of the following statement is not equivalent to the other two (assuming that the loop bodies are the same? 1.Maintaining standard precautions related to body fluids. Chapter 27. 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. Bolus tube feedings are associated with dumping syndrome which is a complication of these feedings. -PCM help lower BP (pot,calc,mag), Vital Signs: Assessing Temperature Using a Temporal Artery Thermometer, -usually 0.5 degrees C higher than oral and 1 degree C higher than axillary. Alene Burke RN, MSN is a nationally recognized nursing educator. -Apply water soluble lubricant to the nares as necessary Tachycardia, tachypnea, INCREASED R, HYPOtension, HYPOxia, weak pulse, fatigue, weakness, thirst, dry mucous membranes, GI upset, oliguria, decreased skin turgor, decreased capillary refill, diaphoresis, cool clamy skin, orthostatic hypotension, fattened neck veins!!! 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. -Comfortable environment. Determine log1048=log10(8)(6)\log _{10} 48=\log _{10}(8)(6)log1048=log10(8)(6), and compare to log108+\log _{10} 8+log108+ log106\log _{10} 6log106. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. Full Document. Reduced skin turgor vs. edema, 1. daily 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. total parenteral nutrition solutions A nurse has just inserted an NG tube for a client. -Stand 20 feet away. Which of the following assessment findings indicates that the catheter requires irrigation? -clarifying Explain. A nurse is caring for a client who has a sodium level of 125 mEq/L. Adequate nutrition is dependent on the client's ability to eat, chew and swallow. Drinks ( coffee, soft drinks, tea etc. Which of the following instructions should the nurse include in the teaching? Wash hands before and after client contact. CHECK CIRCULATION EVERY 3 HRS?? Assess the client for orthostatic hypotension. -To clean the ear mold, use mild soap and water while keeping the hearing aid dry. A 16-year-old client who is married. Step 13. Measure with a graduated container. The answer will have a profound effect on the situation and the client. 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. A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. ".0t4pt$e(A0& C1d2c8d}RJ 8/iF30yLw #t 2.Urine output < 30 mL/hr or 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. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Tube placement is determined by aspirating the residual and checking the pH of the aspirate and also with a radiography, and/or by auscultating the epigastric area with the stethoscope to hear air sounds when about 30 mLs of air are injected into the feeding tube. Discharge Care She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." A nurse is caring for a client who does not speak the same language as the nurse. Emesis is monitored and measured in terms of mLs or ccs. Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. "We need to document the exact mediation you were taking because you might be allergic to it.". -Monitor patency of catheter. 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 Step 10 c. Measure and record all fluid intake: 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. Apply intermittent suction when withdrawing the catheter. A block oscillating on a spring has an amplitude of 20 cm. Which of the following foods should the nurse suggest that the client ass to his diet? -Read smallest line client is able to read. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following responses should the nurse make? 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. 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. Identify patients with impaired what? Continuous tube feedings are typically given throughout the course of the 24 hour day. (Select all that apply). Significant fluid losses can result from diarrhea, vomiting and nasogastric suctioning; and abnormal losses of electrolytes and fluid and retention can result from medications, such as diuretics or corticosteroids. Decreased attention to the presence of pain can decrease perceives pain level. Measure and record all fluid intake. The nurse opens the sterile field on a wet surface. 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. 232), -Antiembolic stockings *Chapter 32. A nurse is caring for a group of clients on a medical-surgical unit. 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. An x-ray shows the end of the tube above the pylorus. 38% to 47% for Females -DO NOT DELEGATE CHECKING FOR ORTHOSTATIC HYPOTENSION Urinary Elimination: Teaching About Kegel Exercises, Tighten pelvic muscles for a count of 10, relax slowly for a count of 10, and repeat in sequences of 15 in lying-down, sitting, and standing positions, Vital Signs: Assessing a Client's Blood Pressure, -Ortho- waif 1 to 3 mins after sitting to get BP Caluculate, Fluid intake from the tube feedings Insert the IV catheter without using a tourniquet. Fluid losses occur with normal bodily functions like urination, defecation, and perspiration and with abnormal physiological functions such as vomiting and diarrhea. 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. 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. Accuracy for I&O is critical and what will physicians use these findings for: prescription of medications and IV fluids. 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 actions should the nurse include? fluid restrictions, such as a low-sodium diet. 1) ans)Description of skill: Calculating a patients daily intake will require you to record all fluids that go into the patient. Identify patients on what meds that influence fluid balance? be measured and calculated in mL (1 ox = 30mL). -inspect breasts in front of mirror and palpate in shower blood components 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. 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. "When descending stairs, I will first shift my weight to my right leg.". If the capacitor has a vacuum between plates that are spaced by 0.30mm0.30 \mathrm{~mm}0.30mm, what is the energy density (the energy per unit volume)? 11). 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. Determine the molecular formula of a compound that has the following composition: 48.648.648.6 percent C,8.2\mathrm{C}, 8.2C,8.2 percent H\mathrm{H}H, and 43.243.243.2 percent O\mathrm{O}O, and the molar mass is approximately 148g/mol148 \mathrm{~g} / \mathrm{mol}148g/mol. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Course Hero is not sponsored or endorsed by any college or university. 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 Information About a Procedure, Legal Responsibilities: Identifying Torts, Legal Responsibilities: Nursing Role While Observing Client Care, Legal Responsibilities: Responding to a Client's Inquiry About Surgery, Legal Responsibilities: Teaching About Advance Directives, Legal Responsibilities: Teaching About Informed Consent, The Interprofessional Team: Coordinating Client Care Among the Health Care Team, The Interprofessional Team: Obtaining a Consult From an Interprofessional Team Member, Therapeutic Communication: Providing Written Materials in a Client's Primary Language, Adverse effects, Interactions, and Contraindications: Priority Assessment Findings, Diabetes Mellitus: Mixing Two Insulins in the Same Syringe, Dosage Calculation: Calculating a Dose of Gentamicin IV, Dosage Calculation: Correct Dose of Diphenhydramine Solution, Intravenous Therapy: Inserting an IV Catheter, Intravenous Therapy: Medication Administration, Intravenous Therapy: Priority Intervention for an IV Infusion Error, Intravenous Therapy: Promoting Vein Dilation Prior to Inserting a Peripheral IV Catheter, Intravenous Therapy: Recognizing Phlebitis, intravenous Therapy: Selection of an Intravenous Site, Pharmacokinetics and Routes of Administration: Enteral Administration of Medications, Pharmacokinetics and Routes of Administration: Preparing an Injectable Medication From a Vial, Pharmacokinetics and Routes of Administration: Self-Administration of Ophthalmic Solutions, Pharmacokinetics and Routes of Administration: Teaching About Self-Administrationof Clotrimazole Suppositories, Safe Medication Administration and Error Reduction: Administering a Controlled Substance, Safe Medication Administration and Error Reduction: Con rming a Client's Identity, Airway Management: Performing Chest Physiotherapy, Airway Management: Suctioning a Tracheostomy Tube, Client Safety: Priority Action When Caring for a Client Who Is Experiencing a Seizure, Fluid Imbalances: Indications of Fluid Overload, Grief, Loss, and Palliative Care: Manifestations of Cheyne-Stokes Respirations, Pressure Injury, Wounds, and Wound Management: Performing a Dressing Change, Safe Medication Administration and Error Reduction: Priority Action When Responding to a Medication Error, Vital Signs: Caring for a Client Who Has a High Fever, Coping: Manifestations of the Alarm Stage of General Adaptation Syndrome, Coping: Priority Intervention for a Client Who Has a Terminal Illness, Data Collection and General Survey: Assessing a Client's Psychosocial History, Grief, Loss, and Palliative Care: Identifying Anticipatory Grief, Grief, Loss, and Palliative Care: Identifying the Stages of Grief, Grief, Loss, and Palliative Care: Providing End-of-Life Care, Grief, Loss, and Palliative Care: Therapeutic Communication With the Partner of a Client Who Has a Do-Not-Resuscitate Order, Self-Concept and Sexuality: Providing Client Support Following a Mastectomy, Therapeutic Communication: Communicating With a Client 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 Enteral Feedings: Verifying Tube Placement, Older Adults (65 Years and Older): Expected Findings of Skin Assessment, Preoperative Nursing Care: Providing Preoperative Teaching to a Client, Thorax, Heart, and Abdomen: Priority Action for Abdominal Assessment, Urinary Elimination: Selecting a Coud Catheter, Vital Signs: Palpating Systolic Blood Pressure, Client Safety: Care for a Client Who Requires Restraints, Client Safety: Implementing Seizure Precautions, Client Safety: Planning Care for a Client Who Has a Prescription for Restraints, Client Safety: Priority Action for Handling Defective Equipment, Client Safety: Priority Action When Responding to a Fire, Client Safety: Proper Use of Wrist Restraints, Ergonomic Principles: Teaching a Caregiver How to Avoid Injury When Repositioning a Client, Head and Neck: Performing the Weber's Test, Home Safety: Client Teaching About Electrical Equipment Safety, Home Safety: Evaluating Client Understanding of Home Safety Teaching, Home Safety: Teaching About Home Care of Oxygen Equipment, Infection Control: Caring for a Client Who Is Immunocompromised, Infection Control: Identifying the Source of an Infection, Infection Control: Implementing Isolation Precautions, Infection Control: Isolation Precautions While Caring for a Client Who Has Influenza, Infection Control: Planning Transmission-Based Precautions for a Client Who Has Tuberculosis, Infection Control: Protocols for Multidrug-Resistant Infections, Infection Control: Teaching for a Client Who is Scheduled for an Allogeneic Stem Cell Transplant, Information Technology: Action to Take When a Visitor Reports a Fall, Information Technology: Situation Requiring an Incident Report, Intravenous Therapy: Action to Take After Administering an Injection, Medical and Surgical Asepsis: Disposing of Biohazardous Waste, Medical and Surgical Asepsis: Performing Hand Hygiene, Medical and Surgical Asepsis: Planning Care for a Client Who Has a Latex Allergy, Medical and Surgical 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. 3.change in weight. 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 . Y^+hh63&P1ZEA B!yyO:*XFGGDL+,5la`1Z{W|RgOM;EZc4[.