-probing Which of the following actions should the nurse take? Liquid medications, Count all liquid meds. 220), -position client using corrective devices (ex. What is the normal Hct range for Females and Males? Enteral feedings can consist of commercially prepared formulas that vary in terms of their calories, fat content, osmolality, carbohydrates and protein as well as given with regular pureed foods. 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. Which of the following actions should the nurse take first? -To clean the ear mold, use mild soap and water while keeping the hearing aid dry. Save. 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 Which of the following assessment findings indicates that the catheter requires irrigation? Record intake when: What do you do if one or more patient's in the same room? Make sure two fingers can fit under the sleeves. ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music 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. -Nurse should not require the client to use these strategies in place of pharmacological pain measures. -Read smallest line client is able to read. -Have client lie supine with arms at both sides and knees slightly bent. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? -ROM exercises -Occlusion of the NG tube can lead to distention Which of the following pieces of information is the priority for the nurse to provide? Apply clean gloves. Which of the following food items should the nurse recommend as a good source of complete protein? Educate the client on the importance calculating fluid intake. total parenteral nutrition solutions Download. 3. with the same scale Step 11. hbbd```b``z "s@$U0[D2'`LIv0yL $[9-gt&F7 !30}` $&w Which of the following actions should the charge nurse identify as contaminating the sterile field? The aging population as well as Infants and young children are at greatest risk for fluid imbalances and the results of these imbalances. blood components Although more clients should reduce their weight, there are some clients that have to be encouraged to gain weight. Nutrition and oral hydration Basic concept template (calculating fluid and intake) Expert Answer 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 me Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the body. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. Which of the following methods should the nurse use as a psychomotor approach to learning? Nursing skill Fluid imbalances net fluid intake - Studocu requires a prescription Fluid Imbalances- Calculating a Client's Net Fluid Intake .docx 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. -knee flexion: flex and extend the legs at the knees 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. hb```, eagGHm A nurse is admitting a client who has been having frequent tonic-clonic seizures. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. CHECK CIRCULATION EVERY 3 HRS?? Step 13 b. These special diets, some of the indications for them, and the components of each are discussed below. This interactive, online tutorial was designed to break down and simplify one of the most difficult subjects in nursing school, Pharmacology. -Keep replacement batteries. Bowel Elimination: Assisting a Client to Use a Fracture Pan, We use fracture pans for supine patients and for patients in body casts or leg casts.For client using a fracture pan, raise the head of the bed to 30 DEGREES (semi-Fowler's : 30-45 degrees), Complementary and Alternative Therapies: Contraindications for Receiving Acupuncture, Complementary and Alternative Therapies: Contraindications for the Use of Magnet Therapy, Complementary and Alternative Therapies: Identifying Potential Medication Interactions With Ginkgo Biloba, Ergonomic Principles: Safely Transferring a Client From the Bed to a Chair, -Use two or more people to transfer patient, Fluid Imbalances: Assessment Findings of Extracellular Fluid Volume Deficit (CP card #164). endstream endobj startxref The nurse is preparing to auscultate the pulmonary valve. After confirming the fire, which of the following actions should the nurse take next? The body mass index is calculated using the client's bodily weight in kg and the height of the client in terms of meters. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 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: Assess client ability to eat (e.g., chew, swallow) Assess client for actual/potential specific food and medication interactions. Which of the following responses should the nurse make? `record I&O A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. CT collection devices are changed when they become FULL. For which of the following practices should the nurse intervene? The client's roommate reports that the client fell getting out of bed. A nurse is caring for a client who has an indwelling urinary catheter. Step 8. -DO NOT DELEGATE CHECKING FOR ORTHOSTATIC HYPOTENSION : 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). 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. "We need to document the exact mediation you were taking because you might be allergic to it.". A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. What is the normal urine specimen gravity? A nurse is caring for a client who has an aggressive form of prostate cancer. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? bradycardia vs. tachycardia A nurse is caring for a client who has a sodium level of 125 mEq/L. -Cutaneous stimulation- transcutaneous electrical nerve stimulation(TENS) heat, cold, therapeutic touch, and massage. -Comfortable environment. Sensory Perception: Evaluating a Client's Understanding of Hearing Aid Use (ATI pg. A block oscillating on a spring has an amplitude of 20 cm. A nurse is teaching a client about dietary management of hypercholesterolemia. Measure the client's BP after the nurse administers an antihypertensive medication. Pain Management: Suggesting Nonpharmacological Pain Relief for a Client, Rest and Sleep: Identifying Findings that Indicate Sleep Deprivation, Illness Delegation and Supervision: Delegating Client Care to an Assistive Personnel, Delegation and Supervision: Delegating Tasks for a Client Who is Postoperative to an Assistive Personnel, Delegation and Supervision: Identifying a Task to Delegate to an Assistive Personnel, Ethical Responsibilities: Demonstrating Client Advocacy, Ethical Responsibilities: Recognizing an Ethical Dilemma (ATI pg. Caluculate, Fluid intake from the tube feedings Discharge Care After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next? 3. mobility. 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. All clients, however, must have a balanced and healthy diet with all of the food groups. calculating a clients net fluid intake ati remediation Monitor I&O for clients with fluid or electrolyte imbalances And then each eye separately. ".0t4pt$e(A0& C1d2c8d}RJ 8/iF30yLw #t Bolus enteral feedings are given using a large syringe and they are typically given up to 6 times a day over the course of about 15 minutes. Reduced skin turgor vs. edema, 1. daily Leave 1-2 inches of catheter at end of penis, Urinary Elimination: Maintaining an Indwelling Urinary Catheter (ATI pg. A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? -Apply protective barrier creams. Solved ACTIVE LEARNING TEMPLATE Nursing Skill STUDENT NAME - Chegg A nurse is completing an admission assessment of an older adult client. 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. Decreased attention to the presence of pain can decrease perceives pain level. 2003-2023 Chegg Inc. All rights reserved. Which of the following findings should the nurse identify as a potential indication of abuse? Fluid losses occur as the result of vomiting, diarrhea, a high temperature, the presence of ketoacidosis, diuretic medications and other causes. 253), -Use soap and water at insertion site. Emotional or mental stress 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. 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. Which of the following actions should the nurse take to prevent the spread of infection? Step 12. The doctor's order for these nutritional supplements states the name of the specific nutritional supplement and the number of cans per day. 2. unconscious patients Wash the client's body . Intake includes all liquids (oral fluids, food that liquefy at room . Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. Greater than 7.5% in 3 months indicates a significant weight loss 6 For which of the following clients should the nurse consult the provider before using this complementary therapy? Which of the following actions should the nurse take? 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. ATI Remediation Fundamentals - ATI Remediation Fundamentals Ethical Responsibilities: Demonstrating - Studocu Remediation Notes ati remediation fundamentals ethical responsibilities: demonstrating client advocacy advocacy refers to nurses role in helping clients Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew After securing a safe environment, which of the following actions should the nurse take next? 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**. Marie Wegener - DSDS-Gewinnerin 2018 . A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following actions should the nurse add to the client's plan of care? ***Relaxation- meditation, yoga, and pregressive muscle relaxation. status indicator informati, Julie S Snyder, Linda Lilley, Shelly Collins, Foundations for Population Health in Community and Public Health Nursing. 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. 232), -Antiembolic stockings The client asks what would happen if she arrived at the emergency department and had difficulty breathing. -Promote a quiet hospital environment. Measure with a medicine cup. The calculations for both of these variables were discussed above. . 34% to 40% for Males. Identify patients on what meds that influence fluid balance? When working with the client through an interpreter, which of the following actions should the nurse take? Young adults at risk for: Which of the following changes should the nurse identify as an indication that the treatment was successful? A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. University: Chamberlain University. -Keep skin clean and dry. -Divide abdomen in four quadrants in head. -Use lowest setting that allowed hearing without feedback . When the nurse asks if the client would like to discuss any concerns, the client declines. -make sure it's below level of bladder, Urinary Elimination: Preventing Skin Breakdown (ATI pg 256). Obtain the pronouncement of death from the provider . -Violent death and injury. Which of the following actions should the nurse plan to take first? Make sure the client wears a mask when outside her room if there is construction in the area. -Discomfort (look at ATI page 334 for more details) 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 . Use a communication board to ask what the client wants for lunch. -First number is the distance client is standing from chart. -Release no faster than 2-3 mmHg per second 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. The answer will have a profound effect on the situation and the client. -press the scan button and hold probe flat on forehead and move across forehead Apply intermittent suction when withdrawing the catheter. Identify the type of breath sounds. 1) ans)Description of skill: Calculating a patients daily intake will require you to record all fluids that go into the patient. 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. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. -Interruption of pain pathways This is a preview. 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. Home / NCLEX-RN Exam / Nutrition and Oral Hydration: NCLEX-RN. -open ended questions -sleep deprivation Full Document. Nutrition, Feeding, and Eating - ATI Testing Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. *****AVOID: crossing legs, sitting for long periods, wearing restrictive clothing on the lower extremities, putting pillow behind the knee, massaging legs
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