Which of the following instructions should the nurse include in the teaching? 384 Documents. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. bradycardia vs. tachycardia -Assess for manifestations of breakdown. The client's roommate reports that the client fell getting out of bed. 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. -make sure it isn't kinked (what to do FIRST) University: Chamberlain University. Emesis is monitored and measured in terms of mLs or ccs. A nurse enters a client's room ad finds her on the floor. Continuous tube feedings are typically given throughout the course of the 24 hour day. Indirect evidence of intake and output, which includes losses that are not measurable, can be determined with the patient's vital signs, the signs and symptoms of fluid excesses and fluid deficits, weight gain and losses that occur in the short term, laboratory blood values and other signs and symptoms such as poor skin turgor, sunken eyeballs and orthostatic hypotension. Intake includes all liquids (oral fluids, food that liquefy at room . Which of the following changes should the nurse identify as an indication that the treatment was successful? -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!!!) The family member washed out the feeding bag with warm water once every 24 hours. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. Which of the following actions should the nurse add to the client's plan of care? Accuracy for I&O is critical and what will physicians use these findings for: prescription of medications and IV fluids. ATI Fundamentals Practice Exam 2016 Flashcards | Chegg.com Some facilities include pureed vegetables in a full liquid diet Identify the sequence in which the nurse should perform the following steps. -Interruption of pain pathways The client asks what would happen if she arrived at the emergency department and had difficulty breathing. -Apply cuff 2.5 cm 1 in) above antecubital space Compare prescriptions with medications the client received during hospitalization. These special diets, some of the indications for them, and the components of each are discussed below. Download. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. 1. time on collection chamber at specified intervals. -Periodontal disease due to poor oral hygiene Some outputs that are not measurable include respiratory vapors that are exhaled during the respiratory cycle and fluid losses from sweating. Place a client who has tuberculosis in a room with negative-pressure airflow. Talk directly to the client, instead of the interpreter, when speaking. -Consult provider about medicine to help sleep. -Infertility 38% to 47% for Females "It might help me to listen to music while I'm lying in bed.". Because of space constraints, it's not comprehensive. Bruises on the arms in various stages of healing. -Limit waking clients during the night. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. 2. unconscious patients A nurse is caring for a client who is postoperative. (Select all that apply). Full Document. Which of the following statements should the nurse make? Medications, including over the counter medications, interact with foods, herbs and supplements. Measure the client's BP after the nurse administers an antihypertensive medication. Mobility and Immobility: Preventing Thrombus Formation (ATI pg. Make sure two fingers can fit under the sleeves. -Ankle pumps: point toes toward the head and then away from the head. Exercise (promotes sleep as long as it's TWO HOURS BEFORE bed) 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 A pump, similar in terms to an intravenous infusion pump, controls the rate of the tube feeding infusion at the ordered rate. Which of the following responses should the nurse make? Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! 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. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. The nurse is preparing to auscultate the pulmonary valve. Lab Report #11 - I earned an A in this lab class. Reduction of pain stimuli in the environment. 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. 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. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. -Report DARK, coffee-ground, or blood streaked drainage ASAP A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? 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 providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. -Occlusion of the NG tube can lead to distention -Promote a quiet hospital environment. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? -Comfortable environment. Ex. 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. 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. -Cold for inflammation 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 are ionic compound, and which are covalent compounds: RbCl,PF5,BrF3\mathrm{RbCl}, \mathrm{PF}_5, \mathrm{BrF}_3RbCl,PF5,BrF3. -pain Fluid Imbalances: Calculating a Client's Net Fluid Intake _________, Instruct the client and family about any diet or. Requires ability to concentrate. -sleep deprivation For which of the following clients should the nurse consult the provider before using this complementary therapy? 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. Obtain the pronouncement of death from the provider . Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. These client choices and preferences become quite challenging indeed when the client has a dietary restriction. calculating a clients net fluid intake ati nursing skill -probing Chapter 27. It involves a conflict between two moral imperatives. Similar to rectal temps! A nurse is caring for a client who has an indwelling urinary catheter. Intake and Output Calculation NCLEX Review - Registered Nurse RN Which of the following pieces of information is the priority for the nurse to provide? Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. -Limit alcohol and caffeine 4 hr before bed. 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!!! Administer pain medication 45 min before changing the client's dressing. or View 3. excessive perspiration. `record I&O I will be sure to remove my hearing aid before taking a shower.. 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. Intake includes all foods and fluids that are consumed by the client with oral eating, intravenous fluids, and tube feedings; output is the elimination of food and fluids from the body. Ask the client's family members if they would like to view the body . 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 16-year-old client who is married. Which of the following instructions should the nurse provide to the client and his family? Which of the following precautions should the nurse plan for this client? A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. calculating a clients net fluid intake ati nursing skill 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**. -Work related injuries or exposures. Which of the following findings should the nurse identify as a potential indication of abuse? A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Ankle pumps, foot circles, and knee flexion, Mobility and Immobility: Teaching About Reducing the Adverse Effects of Immobility, Nasogastric Intubation and Enteral Feedings: Unexpected Findings (ATI pg 334), -Excoriation of nares and stomach Recorded as 50% of measured volume The nurse opens the sterile field on a wet surface. In which of the following situations does the nurse demonstrate the ethical principle of veracity? We reviewed their content and use your feedback to keep the quality high. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Nutrition, Feeding, and Eating - ATI Testing hb```, eagGHm Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. Which of the following responses should the nurse make? Nurses assess edema in terms of its location and severity. -Cognitive-behavioral measures- changing the way a client perceives pain, and physical approaches to improve comfort. Calculating Appropriate Intake of Fat Calories Per Day -Lipids provide 9 cal/g of energy and are the densest form of stored energy -The AMDR for fats is approximately 20% to 35% of total calories. Monitor I&O for how long, and what is used for? Some medications interfere with the digestive process and others interact with some foods. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." 1. name Which of the following actions should the nurse include? 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. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. Fluid Imbalances - N/A - Nurs 210 - Studocu Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? In planning this client's care, when should the nurse initiate discharge planning? calculating a clients net fluid intake ati remediation 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. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the charge nurse identify as contaminating the sterile field? Step 13 e. Gastric drainage/ Larger drainage pouches by: opening clamp and pouring into a graduated cup with a 240 mL capacity.`. A nurse is completing an admission assessment of an older adult client. For which of the following practices should the nurse intervene? Observe for signs of hypoxia. 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. Major differences in I & O to the client ' s physician site is preferable for injections. 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. -Apply protective barrier creams. Administer the medication with the needle at a 45 degree angle. how to delete saved games on sims 4 pc; magaddino memorial chapel haunted; A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube.

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