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. (Select all that apply). at end of each shift or a specific time like every 8 hours. Regulate oxygen via nasal cannula at a flow rate no more than 6l/min. Question: Nutrition and oral hydration Basic concept template - Chegg A nurse is reviewing the medical records of a client who has a pressure ulcer. The clients urine color and amount can give us indications. -Consider continuous positive airway pressure(CPAP) Caluculate, Fluid intake from the tube feedings 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. 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. 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. The mathematical rule for calculating the client's BMI is: BMI = kg of body weight divided by height in meters squared. Observe what in the foley cath: color and characteristics of urine in tubing and drainage bag. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. After which of the following observations should the nurse remove the IV catheter? Dehydration occurs when one loses more fluid than is taken in. 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. ***Relaxation- meditation, yoga, and pregressive muscle relaxation. Basic Concept safe medication Administration error reduction, Medication Template Isophane Insulin NPH (Humulin N, Novolin N), RUA Medication Teaching Plan - Abolanle Salami, NR 324 Chapter 017 Med Surg electrolytes sheet-3, NR 324 Week 3 Lab Prep - NR 324 Week 3 Lab Prep, Med surg Altered Fluid and Electrolyte Balance, Nursing Skill Performing a Catheter irrigation, Medical/Surgical Nursing Concepts (NUR242), Organizational Theory and Behavior (BUS 5113), Managing Projects And Programs (BUS 5611), Elementary Physical Eucation and Health Methods (C367), Communication As Critical Inquiry (COM 110), Foundation in Application Development (IT145), Variations in Psychological Traits (PSCH 001), Fundamental Human Form and Function (ES 207), Foundational Concepts & Applications (NR-500), Accounting Information Systems (ACCTG 333), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 12 Seismicity in North America The New Madrid Earthquakes of 1811-1812, Sociology ch 2 vocab - Summary You May Ask Yourself: An Introduction to Thinking like a Sociologist, Lesson 8 Faults, Plate Boundaries, and Earthquakes, How Do Bacteria Become Resistant Answer Key. -Apply protective barrier creams. *Chapter 32. Which of the following actions should the nurse take? Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. * 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. -Towel bath? 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. CHECK CIRCULATION EVERY 3 HRS?? Diet (caffeine consumption before bed) Client Education: Caring for a Client Who Smokes Tobacco, Data Collection and General Survey: Communication Techniques for Gathering Health Information, *Therapeutic communication Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the body. 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. 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. Fatigue 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. 3. excessive perspiration. 11). 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. gloves and dispose in proper receptacle and perform hand hygiene. "We will apply oxygen through a tube in your nose.". Some measurable outputs are urinary elimination, residual that is aspirated when the client is getting a tube feeding, wound drainage, ostomy output, and vomitus. Explain. The doctor's order for these nutritional supplements states the name of the specific nutritional supplement and the number of cans per day. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. 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. . -Second number is at which a visually unimpaired eye can see the same line clearly. Each must have urine receptacles labeled with -Release no faster than 2-3 mmHg per second A nurse is caring for a client who has an aggressive form of prostate cancer. A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Second intercostal space at the left sternal boarder. 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. The residual volume of these feedings is aspirated, measured and recorded at least every 6 hours and the tube is flushed every 4 hours to maintain its patency. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. Assessing the Client for Actual/Potential Specific Food and Medication Interactions, Considering Client Choices Regarding Meeting Nutritional Requirements and/or Maintaining Dietary Restrictions, Applying a Knowledge of Mathematics to the Client's Nutrition, Promoting the Client's Independence in Eating, Providing and Maintaining Special Diets Based on the Client's Diagnosis/Nutritional Needs and Cultural Considerations, Providing Nutritional Supplements as Needed, Providing Client Nutrition Through Continuous or Intermittent Tube Feedings, Evaluating the Side Effects of Client Tube Feedings and Intervening, as Needed, Evaluating the Client's Intake and Output and Intervening As Needed, Evaluating the Impact of Diseases and Illnesses on the Nutritional Status of a Client, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), 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, Non Pharmacological Comfort Interventions, Basic Care & Comfort Practice Test Questions, Assess client ability to eat (e.g., chew, swallow), Assess client for actual/potential specific food and medication interactions, Consider client choices regarding meeting nutritional requirements and/or maintaining dietary restrictions, including mention of specific food items, Monitor client hydration status (e.g., edema, signs and symptoms of dehydration), Apply knowledge of mathematics to client nutrition (e.g., body mass index [BMI]), Manage the client's nutritional intake (e.g., adjust diet, monitor height and weight), Promote the client's independence in eating, Provide/maintain special diets based on the client diagnosis/nutritional needs and cultural considerations (e.g., low sodium, high protein, calorie restrictions), Provide nutritional supplements as needed (e.g., high protein drinks), Provide client nutrition through continuous or intermittent tube feedings, Evaluate side effects of client tube feedings and intervene, as needed (e.g., diarrhea, dehydration), Evaluate client intake and output and intervene as needed, Evaluate the impact of disease/illness on nutritional status of a client, Personal beliefs about food and food intake, A client with poor dentition and misfitting dentures, A client who does not have the ability to swallow as the result of dysphagia which is a swallowing disorder that sometimes occurs among clients who are adversely affected from a cerebrovascular accident, A client with an anatomical stricture that can be present at birth, The client with side effects to cancer therapeutic radiation therapy, A client with a neurological deficit that affects the client's vagus nerve and/or the hypoglossal cranial nerve which are essential for swallowing and the prevention of dangerous and life threatening aspiration, 18.5 to 24.9 is considered a normal body weight. 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.