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. The answer will have a profound effect on the situation and the client. 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. -Limit waking clients during the night. Meds (bronchodilators and antihypertensives can cause insomnia), Rest and Sleep: Interventions to Promote Sleep (ATI pg 218). Some of these interactions are synergistic and others are antagonistic, that is these interactions can increase and potentiate the effects of the medication(s) and others neutralize and inhibit the therapeutic effects of the medication. In planning this client's care, when should the nurse initiate discharge planning? Wash the client's body . -Infertility 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. -Apply water soluble lubricant to the nares as necessary 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 pieces of information is the priority for the nurse to provide? Measure the drainage at the : end of the shift, use appropriate containers and notice color and characteristics. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? -Consider continuous positive airway pressure(CPAP) Fluid Imbalances: Calculating a Client's Net Fluid Intake Include volume intake to get a net fluid balance calculation as well (assuming no other fluid losses) Weight, total urine output, hours, and fluid intake. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Each must have urine receptacles labeled with 1. name 2. bed location Step 11. A nurse is caring for a client who does not speak the same language as the nurse. From a legal perspective, which of the following actions should the nurse take next? -Cleanse three times a day and after defecation. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." 1.swallowing 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. The nurse should set the pump to deliver how many mL/Hr? A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. 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. -Routine tasks- bed making, specimen collection, I&O, Vital signs (Stable Clients). Chapter 27. Use a communication board to ask what the client wants for lunch. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. A problem is an ethical dilemma when: A review scientific data is not enough to solve it. such as Which of the following statements should the nurse document? -clarifying This is a preview. -make sure it isn't kinked (what to do FIRST) At times, abdominal cramping and diarrhea can be prevented by slowing down the rate of the feeding. Although more clients should reduce their weight, there are some clients that have to be encouraged to gain weight. 1) ans)Description of skill: Calculating a patients daily intake will require you to record all fluids that go into the patient. A nurse is caring for a group of clients on a medical-surgical unit. Sweating is a cooling off response to intrapersonal and extrapersonal hot temperatures. 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. University: Chamberlain University. In combination, these forces push fluids into the interstitial spaces. -Acupuncture and acupressure- stimulating subcutaneous tissues at specific points using needles or the digits. The client's roommate reports that the client fell getting out of bed. -make sure it's below level of bladder, Urinary Elimination: Preventing Skin Breakdown (ATI pg 256). After which of the following observations should the nurse remove the IV catheter? 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 Step 13 e. Gastric drainage/ Larger drainage pouches by: opening clamp and pouring into a graduated cup with a 240 mL capacity.`. Ask the client's family members if they would like to view the body . Apply clean gloves. A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Accuracy for I&O is critical and what will physicians use these findings for: prescription of medications and IV fluids. Dehydration occurs when one loses more fluid than is taken in. Which of the following actions should the nurse take? Emesis is monitored and measured in terms of mLs or ccs. Record intake when: What do you do if one or more patient's in the same room? 3.change in weight. 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. Identify patients on what meds that influence fluid balance? A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. 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. 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. -release scan button for reading, Young Adults (20 to 35 Years): Teaching Appropriate Health Promotion Guidelines (ATI pg 115). Which of the following types of transmission precautions should the nurse initiate? Intake includes all liquids (oral fluids, food that liquefy at room . If using bed scale, use the same amount of linen each day and reset the scale to zero if possible. 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. -Heat to increase blood flow and to reduce stiffness Place a name tag on the body. A nurse is reviewing the medical records of a client who has a pressure ulcer. Step 11. Some of the side effects and complications associated with tube feedings, their prevention and their interventions are discussed below. Which of the following foods should the nurse suggest that the client ass to his diet? A nurse in a provider's office is assessing the deep tendon reflexes of a client. And then each eye separately. 2. bed location 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. -active listening A block oscillating on a spring has an amplitude of 20 cm. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following precautions should the nurse plan for this client? The client's respirations are noisy from secretions in her airway and she is short of breath. 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 . When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur. Administer pain medication 45 min before changing the client's dressing. Over which of the following locations should the nurse place the bell of the stethoscope? (Select all that apply). Clients must be encouraged to drink these supplements as ordered and the client's flavor preference should also be considered and provided to the client whenever possible. Specific risk factors associated with fluid excesses include poor renal functioning, medications like corticosteroids, Cushing's syndrome, excessive sodium intake, heart failure, hepatic failure and excessive oral and/or intravenous fluids. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Which of the following actions should the nurse take? Tube placement is determined by aspirating the residual and checking the pH of the aspirate and also with a radiography, and/or by auscultating the epigastric area with the stethoscope to hear air sounds when about 30 mLs of air are injected into the feeding tube. -Note smallest line client can read correctly. Monitor I&O for how long, and what is used for? Ex. 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. -related to change in surroundings, Thorax, Heart, and Abdomen: Client Teaching About Breast Self-Examination. 253), -Use soap and water at insertion site. a graduated container clearly marked with: 3. excessive perspiration. How to calculate tube feedings: Parenteral fluids 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.
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