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. Emesis is monitored and measured in terms of mLs or ccs. 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. Info More info. Some of the side effects and complications associated with tube feedings, their prevention and their interventions are discussed below. -Periodontal disease due to poor oral hygiene 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 is completing an admission assessment of an older adult client. -Routine tasks- bed making, specimen collection, I&O, Vital signs (Stable Clients). 3. edema, reduced cardiac output, and hypotension. Each must have urine receptacles labeled with 1. name 2. bed location Step 11. 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. In combination, these forces push fluids into the interstitial spaces. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following changes should the nurse identify as an indication that the treatment was successful? -Infertility Reduction of pain stimuli in the environment. Which of the following actions should the nurse take? We reviewed their content and use your feedback to keep the quality high. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. 1) ans)Description of skill: Calculating a patient's daily intake will require you to record all fluids that go into the patient. blue line trax schedule; selena gomez makeup ulta; george m whitesides net worth; Media. -Sexually transmitted Infections -knee flexion: flex and extend the legs at the knees Which of the following actions should the nurse take as part of the medication reconciliation process? Step 8. When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur. To convert oz to mL, simply multiply the amount of oz by 30. Which of the following instructions should the nurse provide to the client and his family? University: Chamberlain University. %%EOF Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? "When descending stairs, I will first shift my weight to my right leg.". A nurse in a provider's office is assessing the deep tendon reflexes of a client. Obtain the pronouncement of death from the provider . The nurse should set the pump to deliver how many mL/Hr? Apply intermittent suction when withdrawing the catheter. 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. Which of the following interventions should the nurse implement to prevent infection? These clients should have attractive and preferred food preferences and, at times, they may need dietary supplements and medications to stimulate their appetite. 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. Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? Mobility and Immobility: Preventing Thrombus Formation (ATI pg. a "hat" into patient voids or a graduated container. -sleep deprivation 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. 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. KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? Which of the following actions should the nurse take? CT collection devices are changed when they become FULL. Second intercostal space at the left sternal boarder. The aging population as well as Infants and young children are at greatest risk for fluid imbalances and the results of these imbalances. This interactive, online tutorial was designed to break down and simplify one of the most difficult subjects in nursing school, Pharmacology. 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? Thorax, Heart, and Abdomen: Steps to Take When Performing an Abdominal Assessment(ATI pg 157). When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action? 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. 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. Emotional or mental stress This includes oral intake, tube feedings, intravenous fluids,medications, total parenteral nutrition, lipids, blood pro, ACTIVE LEARNING TEMPLATE Nursing Skill STUDENT NAME SKILL NAME REVIEW MODULE CHAPTER Description of Skill Indications CONSIDERATIONS Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions. Check the cord routinely for frays or tearing. 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. Patient weight changes approximate a gold standard to determine fluid status. 0 : an American History (Eric Foner), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Psychology (David G. Myers; C. Nathan DeWall), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham). The patient calculating a patient ' s daily intake will require you to record all fluids that go the! . 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. -Apply cuff 2.5 cm 1 in) above antecubital space Ex. A nurse is caring for a client who has an aggressive form of prostate cancer. 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. endstream endobj startxref A nurse has just inserted an NG tube for a client. 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. Young adults at risk for: 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. A pump, similar in terms to an intravenous infusion pump, controls the rate of the tube feeding infusion at the ordered rate. The family member washed out the feeding bag with warm water once every 24 hours. learn more ATI Nursing Blog At times, abdominal cramping and diarrhea can be prevented by slowing down the rate of the feeding. Y^+hh63&P1ZEA B!yyO:*XFGGDL+,5la`1Z{W|RgOM;EZc4[. Ex. A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. -Evaluate both eyes. 2. bed location 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. A nurse is caring for a child who has a prescription for a blood transfusion. The mathematical rule for calculating the client's BMI is: BMI = kg of body weight divided by height in meters squared. In which of the following situations does the nurse demonstrate the ethical principle of veracity? "I am available to talk if you should change your mind.". Some medications interfere with the digestive process and others interact with some foods. -Acupuncture and acupressure- stimulating subcutaneous tissues at specific points using needles or the digits. Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators about the client's nutritional status. Exercise (promotes sleep as long as it's TWO HOURS BEFORE bed) This includes oral intake, tube feedings, intravenous fluids, medications, total parenteral nutrition, lipids, blood pro View the full answer Transcribed image text: dehydration and fluid overload Explain. 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. A nurse is teaching a client about dietary management of hypercholesterolemia. Experts are tested by Chegg as specialists in their subject area. -Assess for manifestations of breakdown. blood components Full Document. When working with the client through an interpreter, which of the following actions should the nurse take? -When hearing aids are not in use for an extended time, turn it off and remove the battery. Which of the following foods should the nurse suggest that the client ass to his diet? A nurse is caring for a client who has a terminal diagnosis and whose health is declining. 3.change in weight. -Cold for inflammation **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). A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. Course: NR 324 ADULT HEALTH. *Chapter 32. "We can talk about advance directives, and I can also give you some brochures about them.". 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. Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. -remove stockings EVERY 8 hours 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. Over which of the following locations should the nurse place the bell of the stethoscope? Which of the following findings should the nurse identify as a potential indication of abuse? Identify patients with impaired what? Enteral nutrition is given to clients when, for one reason or another, the client is not getting sufficient calories and/or nutrients with oral meals and eating. Which of the following actions should the nurse take? Intermittent tube feedings are typically given every 4 to 6 hours, as ordered, and the volume of each of these intermittent feedings typically ranges from 200 to 300 mLs of the formula that is given over a brief period of time for up to one hour. For which of the following clients should the nurse consult the provider before using this complementary therapy? Which of the following assessment findings should the nurse expect to confirm correct tube placement? Some outputs that are not measurable include respiratory vapors that are exhaled during the respiratory cycle and fluid losses from sweating. of dosages and solution rates in 500ml infusing 1000. A urinary output of less than 30 mLs or ccs per hour is considered abnormal. "People in middle adulthood often find satisfaction in nurturing and guiding young people.". A nurse is teaching a client and his family how to care for the client's tracheostomy at home. A nurse is caring for a client who has a heart murmur. Bolus tube feedings are associated with dumping syndrome which is a complication of these feedings. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. Some of these factors, as previously discussed, include gender, cultural practices and preferences, ethnic practices and preferences, spiritual and religious practices and preferences and, simply, personal preferences that have no basis in the client's spiritual, religious, cultural, or gender practices and preferences. A nurse is caring for a client who is postoperative. -Help clients establish and follow a bedtime routine. The clients urine color and amount can give us indications. -pain The family member providing the feedings reports that the client has begun to have diarrhea. -Use lowest setting that allowed hearing without feedback . Observe for signs of hypoxia. 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. RegisteredNursing.org does not guarantee the accuracy or results of any of this information. 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. The method above is quite cumbersome because it entails weighing the food and then calculating the number of calories. -Monitor patency of catheter. The nurse opens the sterile field on a wet surface. For example, Americans in the southern area of the United States may prefer fried foods like fried chicken instead of a healthier piece of broiled or baked chicken, however, when they are affected with high cholesterol levels, modifications in this diet must be made; similarly, when a member of the Hindu religion is a vegetarian and they lack protein, the diet of this person must also be modified. -Note smallest line client can read correctly. -Ask the client to urinate before the abdominal exam. 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. 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. The volume of bolus enteral feedings is usually about 200 to 400 mLs but not over 500 mLs per feeding. Place a client who has tuberculosis in a room with negative-pressure airflow. -Consult provider about medicine to help sleep. This is a preview. Home / NCLEX-RN Exam / Nutrition and Oral Hydration: NCLEX-RN. Educate the client on the importance calculating fluid intake. -Release no faster than 2-3 mmHg per second 2. bed location. Step 10 c. Measure and record all fluid intake: -Second number is at which a visually unimpaired eye can see the same line clearly. 1.Maintaining standard precautions related to body fluids. terrenos en venta houston Queijo Flamengo $ 17.00 - $ 35.00; cuphead infinite health mod Queijo da Serra Amanteigado $ 50.00; influencers church salisbury Biscoitos Amores $ 8.50; grenada wedding traditions Alho e salsa $ 7.50; robert spike'' mickens cause of death Morcela $ 12.25 fluid restrictions, such as a low-sodium diet. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? A nurse is planning care for a client who has fluid overload. 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. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. 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 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. 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 is preparing to administer enoxaparin subcutaneously to a client. 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)? -ADLs- Bathing, grooming, dressing, toileting, ambulating, feeding(without swallowing precautions), positioning. Dehydration occurs when one loses more fluid than is taken in. requires a prescription Although more clients should reduce their weight, there are some clients that have to be encouraged to gain weight. "We need to document the exact mediation you were taking because you might be allergic to it.". PLEASE NOTE: The contents of this website are for informational purposes only. Download. Step 13 e. Gastric drainage/ Larger drainage pouches by: opening clamp and pouring into a graduated cup with a 240 mL capacity.`. -Imagery- pleasant thought to divert focus Which of the following precautions should the nurse plan for this client? hVio7+0e'VY@iSo[ip=rB status indicator informati, Julie S Snyder, Linda Lilley, Shelly Collins, Foundations for Population Health in Community and Public Health Nursing. ".0t4pt$e(A0& C1d2c8d}RJ 8/iF30yLw #t 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. 11). -Consider switching the tube to the other naris -Ankle pumps: point toes toward the head and then away from the head. -INSPECTION, AUSCULTATION, PERCUSSION, PALPATION 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. Which of the following assessment findings indicates that the catheter requires irrigation? Pad the client's wrist before applying the restraints. -Limit alcohol and caffeine 4 hr before bed. Which of the following actions should the nurse add to the client's plan of care? Solid intake is monitored and measured in terms of ounces; liquid intake is monitored and measured in terms of mLs or ccs. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. A block oscillating on a spring has an amplitude of 20 cm. -If they get frustrated, stop and come back SEE Basic Care & Comfort Practice Test Questions. * 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 on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Wash the client's body . Pitting edema is assessed and classified as: Some professional literature classifies pitting edema on a scale of 1+ to 4+ with: Dehydration occurs when fluid loses are greater than fluid gains. -Occlusion of the NG tube can lead to distention 3. mobility.
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