calculating a clients net fluid intake ati remediation

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 -Promote a quiet hospital environment. 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. Observe for signs of hypoxia. -First number is the distance client is standing from chart. 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. Reduced skin turgor vs. edema, 1. daily Emotional or mental stress CHECK CIRCULATION EVERY 3 HRS?? For example, the elderly is at risk for alterations in terms of fluid imbalances because of some of the normal changes of the aging process and some of the medications that they take when they are affected with a chronic disorder such as heart failure. Emesis is monitored and measured in terms of mLs or ccs. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Step 11. If using bed scale, use the same amount of linen each day and reset the scale to zero if possible. 1. name The answer will have a profound effect on the situation and the client. Some of the medications that impact on the client's nutrition status include thiazide diuretic medications which can decrease the body's ability to absorb vitamin B12 and acetylsalicylic acid which can decrease the amounts of vitamin C, potassium, amino acids, and glucose available to the body because acetylsalicylic acid can lead to the excessive excretion of these substances. Inform patient and family that foley cath drainage bag, and wound, gastric or CT drainage are: closely monitored , measured and recorded and who is responsible. 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. After confirming the fire, which of the following actions should the nurse take next? Which of the following changes should the nurse identify as an indication that the treatment was successful? The mathematical rule for calculating the client's BMI is: BMI = kg of body weight divided by height in meters squared. 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. 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. -Limit fluids 2 to 3 hr before bedtime. 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. -Acupuncture and acupressure- stimulating subcutaneous tissues at specific points using needles or the digits. 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. Which of the following actions should the nurse take as part of the medication reconciliation process? Some medications interfere with the digestive process and others interact with some foods. 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**. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Associations task force on competency and education for the nursing team members. Clients can be instructed to count calories by weighing the food that will be eaten and then multiply this weight in grams by the number of calories per gram. 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 A nurse is assessing a client who reports increased pain following physical therapy. 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. -knee flexion: flex and extend the legs at the knees 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. Experts are tested by Chegg as specialists in their subject area. 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. -PCM help lower BP (pot,calc,mag), Vital Signs: Assessing Temperature Using a Temporal Artery Thermometer, -usually 0.5 degrees C higher than oral and 1 degree C higher than axillary. A nurse is caring for a client who has a respiratory infection. -clarifying Nutrition ATI Remediation Flashcards | Quizlet blood components Wash the client's body . Fluid excesses are the net result of fluid gains minus fluid losses. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. How to calculate tube feedings: Parenteral fluids KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? For example, the client's body mass index (BMI) and the "ideal" bodily weight can be calculated using relatively simple mathematics. The residual volume of these feedings is aspirated, measured and recorded prior to each feeding and the tube is flushed before and after each intermittent feeding with about 30 mLs of water and before and after each medication administration to insure and maintain its patency. A nurse is caring for a client who is postoperative. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Patient weight changes approximate a gold standard to determine fluid status. calculating a clients net fluid intake ati nursing skill. Medications, including over the counter medications, interact with foods, herbs and supplements. 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. Young adults at risk for: -Cold for inflammation 100 mL of ice chips = 50 mL of water, Step 10 b. The client's respirations are noisy from secretions in her airway and she is short of breath. The family member washed out the feeding bag with warm water once every 24 hours. Which of the following foods should the nurse suggest that the client ass to his diet? Mobility and Immobility: Preventing Thrombus Formation (ATI pg. ***Distraction- AMbulation, deep breathing, visitors, television, games, prayer, and music These client choices and preferences become quite challenging indeed when the client has a dietary restriction. SEE Basic Care & Comfort Practice Test Questions. Bolus tube feedings are associated with dumping syndrome which is a complication of these feedings. Reduction of pain stimuli in the environment. A simpler method is to read food labels. The assessment of the client's nutritional status is done with a number of subjective and objective data that is collected and analyzed. Which of the following actions should the nurse include? Record intake when: What do you do if one or more patient's in the same room? -Ask the client to urinate before the abdominal exam. -Interruption of pain pathways Liquid medications, Count all liquid meds. -Consider switching the tube to the other naris And then each eye separately. What do you do if one or more patient's in the same room? The nurse is preparing to auscultate the pulmonary valve. Client Education: Caring for a Client Who Smokes Tobacco, Data Collection and General Survey: Communication Techniques for Gathering Health Information, *Therapeutic communication A nurse is admitting a client who has been having frequent tonic-clonic seizures. 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? 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. . of dosages and solution rates in 500ml infusing 1000. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? Administer the medication with the needle at a 45 degree angle. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? Thread the IV catheter so that the hub rests at the insertion site. Bruises on the arms in various stages of healing. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. Determine the molecular formula of a compound that has the following composition: 48.648.648.6 percent C,8.2\mathrm{C}, 8.2C,8.2 percent H\mathrm{H}H, and 43.243.243.2 percent O\mathrm{O}O, and the molar mass is approximately 148g/mol148 \mathrm{~g} / \mathrm{mol}148g/mol. -press the scan button and hold probe flat on forehead and move across forehead Recording the clients weight, total urine output, hours, and fluid intake Description of Skill Indications Outcomes/Evaluation CONSIDERATIONS Nursing Interventions (pre, intra, post) Potential Complications Client Education Nursing Interventions ACTIVE LEARNING TEMPLATES TherapeuTic procedure A9 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. 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. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. 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. Calculate and chart extra fluid with meals, Before the client is reading for preop the client, Not assessing the patient output and intake can, cause potentially serious problems such as. Because of space constraints, it's not comprehensive. Identify patients on what meds that influence fluid balance? 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? 1. name -Use lowest setting that allowed hearing without feedback . Pad the client's wrist before applying the restraints. -Routine tasks- bed making, specimen collection, I&O, Vital signs (Stable Clients). Ex. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Sensory Perception: Evaluating a Client's Understanding of Hearing Aid Use (ATI pg. 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. Step 8. -Occlusion of the NG tube can lead to distention A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Observe what in the foley cath: color and characteristics of urine in tubing and drainage bag. Administer pain medication 45 min before changing the client's dressing. Nutrition and Oral Hydration: NCLEX-RN - Registered nursing University: Chamberlain University. Make sure two fingers can fit under the sleeves. Swelling and coolness are observed at the IV site. Greater than 7.5% in 3 months indicates a significant weight loss 6 For example, the client is assessed using the A, B, C and Ds of a nutritional assessment in addition to the use of some standardized tools such as the Patient Generated Subjective Global Assessment and the Nutrition Screening Inventory. Urinary Elimination: Application of a Condom Catheter, SEE other sets and book After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next? A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following assessment findings should the nurse expect to confirm correct tube placement? 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. A normal diet should consist of all of the food groups including fruits, vegetables, dairy foods, protein and grains according to the United States Department of Agriculture. 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