In addition to a complete assessment of the client's current nutritional status, nurses also collect data that can suggest that the client is, or possibly is, at risk for nutritional deficits. Step 12. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. 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. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music 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 . Clients at risk for inadequate fluid intake include those who are confused and unable to communicate their needs. In which of the following situations does the nurse demonstrate the ethical principle of veracity? -Periodontal disease due to poor oral hygiene -OPTIMAL TIME: right AFTER period A nurse enters a client's room ad finds her on the floor. 0 Some of the side effects and complications associated with tube feedings, their prevention and their interventions are discussed below. 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. Monitor I&O for clients with fluid or electrolyte imbalances A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following actions should the nurse take first? 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? : 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). Wash hands before and after client contact. * 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. 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? The nurse opens the sterile field on a wet surface. Nursing skill Fluid imbalances net fluid intake. Save. A nurse is calculating a client's fluid intake over the past 8 hr. Emesis is monitored and measured in terms of mLs or ccs. a "hat" into patient voids or a graduated container. Use a communication board to ask what the client wants for lunch. -Keep skin clean and dry. -Promote a quiet hospital environment. 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. KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? -Release no faster than 2-3 mmHg per second The answer will have a profound effect on the situation and the client. 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. -make sure it isn't kinked (what to do FIRST) The doctor's order for these nutritional supplements states the name of the specific nutritional supplement and the number of cans per day. -remove stockings EVERY 8 hours 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. How to calculate tube feedings: Parenteral fluids Which of the following instructions should the nurse provide to the client and his family? When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur. Full Document. -Monitor patency of catheter. 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. Solid intake is monitored and measured in terms of ounces; liquid intake is monitored and measured in terms of mLs or ccs. Observe what in the foley cath: color and characteristics of urine in tubing and drainage bag. Explain to the patient and family: Step 10. aMeasure and Record all fluid intake: -Exercise regularly. Which of the following interventions should the nurse implement to prevent infection? Compare prescriptions with medications the client received during hospitalization. There are a number of therapeutic special diets that are for clients as based on their health care problem and diagnosis. -Infertility A simpler method is to read food labels. Which of the following findings should the nurse identify as a potential indication of abuse? Sleep environment A nurse is planning care for a client who has fluid overload. What is the normal urine specimen gravity? 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)? Calculating a patient' s net fluid intake requires nurses to measure, record, and calculate a patients intake and output of liquids. The body mass index is calculated using the client's bodily weight in kg and the height of the client in terms of meters. -Occlusion of the NG tube can lead to distention A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. A urinary output of less than 30 mLs or ccs per hour is considered abnormal. SEE Basic Care & Comfort Practice Test Questions. Requires ability to concentrate. Recorded as 50% of measured volume Administer the medication with the needle at a 45 degree angle. Swelling and coolness are observed at the IV site. (Select all that apply). endstream endobj startxref A problem is an ethical dilemma when: A review scientific data is not enough to solve it. RegisteredNursing.org does not guarantee the accuracy or results of any of this information. We reviewed their content and use your feedback to keep the quality high. -close ended questions Enteral nutrition is most often used among clients who are affected with a gastrointestinal disorder, a chewing and/or swallowing disorder, or another illness or disorder such as inflammatory bowel disorder, a severe burn and anorexia as often occurs as the result of an acute illness, chemotherapy and radiation therapy. A nurse is caring for a group of clients on a medical-surgical unit. Some outputs that are not measurable include respiratory vapors that are exhaled during the respiratory cycle and fluid losses from sweating. Measure CT drainage by marking and recording Percentage weight change calculation (weight change over a specified time): % weight change = (Usual weight - present weight / usual weight) x 100 Greater than 2% in 1 week indicates a significant weight loss. -Help with personal hygiene needs or a back rub prior to sleep to increase comfort. %PDF-1.7 % The number of calories per gram of protein is 4 calories, the number of calories per gram of fat is 9 calories and the number of calories per gram of carbohydrates is 4 calories. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? 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If using bed scale, use the same amount of linen each day and reset the scale to zero if possible. Assistive Personnel: A nurse is teaching a client and his family how to care for the client's tracheostomy at home. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. edema, reduced cardiac output, and hypotension. The volume of bolus enteral feedings is usually about 200 to 400 mLs but not over 500 mLs per feeding. To convert oz to mL, simply multiply the amount of oz by 30. A nurse is caring for a group of clients. Insert the IV catheter without using a tourniquet. Because of space constraints, it's not comprehensive. It involves a conflict between two moral imperatives. 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 Decreased attention to the presence of pain can decrease perceives pain level. 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 or The aging population as well as Infants and young children are at greatest risk for fluid imbalances and the results of these imbalances. What do you do if one or more patient's in the same room? A nurse is caring for a client who is postoperative. -ROM exercises -Cold for inflammation calculating a clients net fluid intake ati nursing skillderidder city council election results. 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. Meds (bronchodilators and antihypertensives can cause insomnia), Rest and Sleep: Interventions to Promote Sleep (ATI pg 218). 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. 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. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. -Implement a bladder training program. Check the cord routinely for frays or tearing. 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. Ex. Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. 2. fluids with medications, Step 10 c. Measure and record all fluid intake: -Consider switching the tube to the other naris Step 10 c. Measure and record all fluid intake: 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. Which of the following actions should the nurse take? Identify the sequence in which the nurse should perform the following steps. Some of the normal changes of the aging process that can lead to an imbalance of fluid include the aging person's loss of the thirst which, under normal circumstances, would encourage the client to drink oral fluids, decreased renal function, and the altered responses that they have in terms of fluid and electrolyte imbalances during the aging process. -Limit alcohol and caffeine 4 hr before bed. hVio7+0e'VY@iSo[ip=rB **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). Which of the following actions should the charge nurse identify as contaminating the sterile field? When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following findings should the nurse expect? University: Chamberlain University. learn more TEST YOUR A & P KNOWLEDGE This online practice exam for Anatomy and Physiology is designed to test your general knowledge. 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 Emotional or mental stress -Limit fluids 2 to 3 hr before bedtime. Which of the following statements should the nurse make? -Discomfort (look at ATI page 334 for more details) 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. CT collection devices are changed when they become FULL. The doctor is notified when the residual volume is excessive and when the tube is not patent or properly placed. Although patient has the right to choose. -Comfortable environment. 399 0 obj <>stream A nurse is assessing a client who reports increased pain following physical therapy. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. such as 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.

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