This interactive, online tutorial was designed to break down and simplify one of the most difficult subjects in nursing school, Pharmacology. Home / NCLEX-RN Exam / Nutrition and Oral Hydration: NCLEX-RN. 399 0 obj <>stream 2.Urine output < 30 mL/hr or -knee flexion: flex and extend the legs at the knees Course Hero is not sponsored or endorsed by any college or university. 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. hypotension vs. hypertension The parents have refused the treatment due to religious beliefs. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Explain. dehydration and fluid overload A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. -Foot circles: rotate the feet in circles at the ankles 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? Measure with a medicine cup. *Chapter 29, 30 and 13. In planning this client's care, when should the nurse initiate discharge planning? Which of the following instructions should the nurse include in the teaching? -open ended questions 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. -DO NOT DELEGATE CHECKING FOR ORTHOSTATIC HYPOTENSION 1.imbalance and report to HCP -make sure it isn't kinked (what to do FIRST) A nurse is preparing to administer enoxaparin subcutaneously to a client. The assessment of the client's nutritional status is done with a number of subjective and objective data that is collected and analyzed. A nurse is caring for a client who does not speak the same language as the nurse. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. The answer will have a profound effect on the situation and the client. 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. Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. 0 The nurse opens the sterile field on a wet surface. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following actions should the nurse take? A nurse is caring for a client who has a respiratory infection. 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. The calculations for both of these variables were discussed above. Which of the following actions should the nurse take to prevent the spread of infection? Which of the following assessment findings indicates that the catheter requires irrigation? -Read smallest line client is able to read. 2. bed location. So, the BMI for a client weighing 75 kg who is 1.72 meters tall is calculated as follows: The ideal body weight is calculated using the client's height, weight and body frame size as classified as small, medium and large. -footboards used to prevent foot drop!! 3. mobility. Greater than 7.5% in 3 months indicates a significant weight loss 6 Assistive Personnel: 1. name A urinary output of less than 30 mLs or ccs per hour is considered abnormal. 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. 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. Critical Points - Topics to Review Topic to Review: ____Nutrition and oral hydration Sub-item: __ Fluid Imbalances: Calculating a Client's Net Fluid Intake Three Critical Points 1.___Fluid intake include any liquid taken in the body 2.____The fluid intake could be oral fluids, ice chips, tube feeding, parenteral fluids, intravenous . The clients urine color and amount can give us indications. Some of the terms and terminology relating to hydration and the client's hydration status that you should be familiar with for your NCLEX-RN examination include these below. 1. antacids of dosages and solution rates in 500ml infusing 1000. All trademarks are the property of their respective trademark holders. Step 11. ( Chapter 40). Some of the terms and terminology relating to nutrition and hydration that you should be familiar with include those below. Medications have a great impact on the client's nutritional status. This is a preview. Fluid Imbalances: Calculating a Client's Net Fluid Intake . hbbd```b``z "s@$U0[D2'`LIv0yL $[9-gt&F7 !30}` $&w 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. A nurse is reviewing the medical records of a client who has a pressure ulcer. 4. comparable clothing. a "hat" into patient voids or a graduated container. Major differences in I & O to the client ' s physician site is preferable for injections. Alene Burke RN, MSN is a nationally recognized nursing educator. Info More info. -Have client lie supine with arms at both sides and knees slightly bent. -Cognitive-behavioral measures- changing the way a client perceives pain, and physical approaches to improve comfort. : 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). 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. 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. 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 planning care for a client who has fluid overload. Measure and record all fluid intake. Which of the following responses should the nurse make? Active Learning Template, nursing skill on fluid imbalances net fluid intake. A nurse has an order to remove sutures from a client. Educate the client on the importance calculating fluid intake. 1. name Which of the following actions should the nurse plan to take first? She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. 253), -Use soap and water at insertion site. 1) ans)Description of skill: Calculating a patient's daily intake will require you to record all fluids that go into the patient. -If they get frustrated, stop and come back Administer the medication with the needle at a 45 degree angle. Intake includes all liquids (oral fluids, food that liquefy at room . A 27-year-old who has schizophrenia. Pitting edema is assessed and classified as: Some professional literature classifies pitting edema on a scale of 1+ to 4+ with: Dehydration occurs when fluid loses are greater than fluid gains. Enteral nutrition can be given on a continuous basis, on an intermittent basis, as a bolus, and also as supplementation in addition to oral feedings when the client is not getting enough oral feedings. Measure CT drainage by marking and recording A nurse is assessing a client who reports increased pain following physical therapy. Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. Edema is most often identified in the dependent extremities such as the feet and the legs; however, it can also become obvious with unusual abdominal distention and swelling. 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. -Imagery- pleasant thought to divert focus Ask the client's family members if they would like to view the body . Current life events A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. A nurse is calculating a client's fluid intake over the past 8 hr. 220), -position client using corrective devices (ex. A nurse on a medical unit is preparing to discharge a client to home. A nurse working in the Emergency Department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. All intake and output should . A pH > 6 indicates that the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract. 34% to 40% for Males. A nurse is admitting a client who is having an exacerbation of heart failure. "It might help me to listen to music while I'm lying in bed.". A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. "We can talk about advance directives, and I can also give you some brochures about them.". 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. requires a prescription 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. learn more TEST YOUR A & P KNOWLEDGE This online practice exam for Anatomy and Physiology is designed to test your general knowledge. -pregnant or postmenopausal: perform BSE on the same day of each month!! A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Ex. These clients should have attractive and preferred food preferences and, at times, they may need dietary supplements and medications to stimulate their appetite. Identify the type of breath sounds. Step 13. fluid restrictions, such as a low-sodium diet. 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. 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. Caluculate, Fluid intake from the tube feedings Dehydration occurs when one loses more fluid than is taken in. "I am available to talk if you should change your mind.". Although patient has the right to choose. Chapter 27. Observe for signs of hypoxia. After which of the following observations should the nurse remove the IV catheter? Monitor I&O for clients with fluid or electrolyte imbalances 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 The family member washed out the feeding bag with warm water once every 24 hours. KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? Explain to the patient and family: Step 10. aMeasure and Record all fluid intake: 3. A nurse is teaching a client about dietary management of hypercholesterolemia. These drinks come in a variety of flavors including chocolate, vanilla and strawberry. Diet (caffeine consumption before bed) 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. What conditions do you want to monitor your patients I&o? Which of the following responses should the nurse make? Save. Each must have urine receptacles labeled with 1. name 2. bed location Step 11. Sign to alert medical personnel of I&O measurement. To convert oz to mL, simply multiply the amount of oz by 30. If the capacitor has a vacuum between plates that are spaced by 0.30mm0.30 \mathrm{~mm}0.30mm, what is the energy density (the energy per unit volume)? How to calculate tube feedings: Parenteral fluids Over which of the following locations should the nurse place the bell of the stethoscope? A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Exercise (promotes sleep as long as it's TWO HOURS BEFORE bed) A nurse is admitting a client who has been having frequent tonic-clonic seizures. Patient weight changes approximate a gold standard to determine fluid status. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? calculating a clients net fluid intake ati nursing skill. Which of the following actions should the nurse take? For example, clients who are affected with cancer may have an impaired nutritional status as the result of anorexia related to the disease process and as the result therapeutic chemotherapy and/or radiation therapy; other clients can have an acute or permanent neurological deficit that impairs their nutritional status because they are not able to chew and/or safely swallow foods and still more may have had surgery to their face and neck, including a laryngectomy for example, or a mechanical fixation of a fractured jaw, all of which place the client at risk for nutritional status deficiencies. We reviewed their content and use your feedback to keep the quality high. When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur. 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. 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. -Release no faster than 2-3 mmHg per second 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 findings should the nurse identify as a potential indication of abuse? Weight clients at the same time , same amount of linen and reset the scale to 0 if possible Insert the IV catheter without using a tourniquet. Clients with poor dentition and missing teeth can be assisted by a dental professional, the nurse and the dietitian in terms of properly fitting dentures and, perhaps, a special diet that includes pureed foods and liquids that are thickened to the consistency of honey so that they can be swallowed safely and without aspiration when the client is adversely affected with a swallowing disorder. -Work related injuries or exposures. 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. -Comfortable environment. 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. Lab Report #11 - I earned an A in this lab class. Young adults at risk for: 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. Check the cord routinely for frays or tearing. Which of the following foods should the nurse suggest that the client ass to his diet? 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. Calculate and chart extra fluid with meals, including juice, soup, ice cream and sherbet, gelatin, water on trays.Before the client is reading for preop the client needs to be NPO to prevent aspiration Not assessing the patient output and intake can cause potentially serious problems such as edema, reduced cardiac output, and hypotension. Fluid Imbalances: Calculating a Client's Net Fluid Intake _________, Instruct the client and family about any diet or. 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 The relative severity of these nutritional status deficits must be assessed and all appropriate interventions must be incorporated into the client's plan of care, in collaboration with the client, family members, the dietitian and other members of the health care team. -Verify suction equipment functions properly, Nutrition and Oral Hydration: Advancing to a Full Liquid Diet (ATI pg 223), Clear liquids plus liquid dairy products, all juices. 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Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. Clients at risk for inadequate fluid intake include those who are confused and unable to communicate their needs. After confirming the fire, which of the following actions should the nurse take next? Which of the following statements should the nurse identify as an indication that the client understands the teaching? endstream endobj startxref 2003-2023 Chegg Inc. All rights reserved. Which of the following food items should the nurse recommend as a good source of complete protein? RegisteredNursing.org Staff Writers | Updated/Verified: Feb 10, 2023. -make sure it's below level of bladder, Urinary Elimination: Preventing Skin Breakdown (ATI pg 256). Women, in contrast to male clients, are at greater risk for alterations in terms of bodily fluids because they tend to have more fat, which contains less fluid, than muscle which contains more bodily fluid. 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. Administer pain medication 45 min before changing the client's dressing. When the nurse asks if the client would like to discuss any concerns, the client declines. Regulate oxygen via nasal cannula at a flow rate no more than 6l/min. 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 . Which of the following findings should the nurse expect? The client asks what would happen if she arrived at the emergency department and had difficulty breathing. -When hearing aids are not in use for an extended time, turn it off and remove the battery. ".0t4pt$e(A0& C1d2c8d}RJ 8/iF30yLw #t View Serial bodyweights are an accurate method of monitoring fluid status One of the most sensitive indicators of patient volume status changes is their bodyweight. ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) Business PLAN OF Pusong Lumpia; QSO 321 1-3: Triple Bottom Line Industry Comparison; Newest. 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 graduated container clearly marked with: -release scan button for reading, Young Adults (20 to 35 Years): Teaching Appropriate Health Promotion Guidelines (ATI pg 115). -OPTIMAL TIME: right AFTER period The family member providing the feedings reports that the client has begun to have diarrhea. 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. A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore."

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