calculating a clients net fluid intake ati remediation

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. -inspect breasts in front of mirror and palpate in shower -Report DARK, coffee-ground, or blood streaked drainage ASAP 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. Obtain the pronouncement of death from the provider . Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 2. vomiting A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following findings should the nurse expect? **SEE other sets for diets, Nutrition and Oral Hydration: Calculating Fluid Intake (ATI pg 223), -Intake includes all liquids: oral fluids, foods that liquify at room temp, IV fluids, IV flushes, IV medications, enteral feedings, fluid installations, catheter irrigants, tube irrigants, Pain Management: Determining effectiveness of Nonpharmacological Pain Relief Measures (ATI pg 238). Which of the following findings should the nurse expect? Thread the IV catheter so that the hub rests at the insertion site. A pH > 6 indicates that the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract. Intake and Output Practice Questions for Nurs, Pharm made easy 4.0: Introduction to Pharmaco, HCM 370 HCPCS pmt. -Divide abdomen in four quadrants in head. -Irrigate the tube to unclog Blockages Example: 67 oz = 2010 mL Miscellaneous: Tube feedings (include free water) IV and central line fluids (TPN, lipids, blood products, medication infusion) 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. -Assess for manifestations of breakdown. After which of the following observations should the nurse remove the IV catheter? Monitor I&O for clients with fluid or electrolyte imbalances She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. -Help clients establish and follow a bedtime routine. A nurse is teaching a client whose left leg is in a cast about using crutches. 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. 1. name KO2\mathrm{KO}_2KO2, and Cl4\mathrm{Cl}_4Cl4 ? Which of the following actions should the nurse take first? This includes oral intake, tube feedings, intravenous fluids, medications, total parenteral nutrition, lipids, blood pro View the full answer Transcribed image text: Sleep environment Lab Report #11 - I earned an A in this lab class. Meds (bronchodilators and antihypertensives can cause insomnia), Rest and Sleep: Interventions to Promote Sleep (ATI pg 218). 2. bed location 27) CNA. 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. What is the nurse responsible for in monitoring I&O? 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 teaching a client and his family how to care for the client's tracheostomy at home. When the nurse asks if the client would like to discuss any concerns, the client declines. Use a communication board to ask what the client wants for lunch. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Consider client choices regarding meeting nutritional . bradycardia vs. tachycardia edema, reduced cardiac output, and hypotension. 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. Which of the following tasks should the nurse assign to an assistive personnel (AP)? 2. at the same time -release scan button for reading, Young Adults (20 to 35 Years): Teaching Appropriate Health Promotion Guidelines (ATI pg 115). A nurse is caring for a client who does not speak the same language as the nurse. 253), -Use soap and water at insertion site. `record I&O -turn on music to comfort them, Integumentary and Peripheral Vascular Systems: Findings to Report From a Skin Assessment, Older Adults (65 Years and Older): Identify Expected Changes in Development, Older Adults (65 Years and Older): Teaching About Manifestations of Delirium, -infection (especially UTI-first manifestation!!!) 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. 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. -Unplanned pregnancies A nurse is caring for a client who is postoperative. RegisteredNursing.org does not guarantee the accuracy or results of any of this information. Which of the following actions should the nurse add to the client's plan of care? Which of the following actions should the nurse take? A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. such as Step 13. The doctor is notified when the residual volume is excessive and when the tube is not patent or properly placed. Which of the following foods should the nurse suggest that the client ass to his diet? Identify the type of breath sounds. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? Sign to alert medical personnel of I&O measurement. -Elevation of edematous extremities to promote venous return and decrease swelling. Which of the following changes should the nurse identify as an indication that the treatment was successful? A simpler method is to read food labels. 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 When working with the client through an interpreter, which of the following actions should the nurse take? 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. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. -OPTIMAL TIME: right AFTER period 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. As previously mentioned, a number of factors impact on the client, their preferences and their choices in terms of the kinds of foods that they want to eat and in terms of the quantity of food that they want to consume. From a legal perspective, which of the following actions should the nurse take next? In addition to planning a diet with the client to increase or decrease their body weight, the client's weight and body mass index should be monitored on a regular basis. Which of the following signatures may the nurse legally witness? Emesis is monitored and measured in terms of mLs or ccs. These special diets, some of the indications for them, and the components of each are discussed below. 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. learn more ATI Nursing Blog Drinks ( coffee, soft drinks, tea etc. 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. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Serial bodyweights are an accurate method of monitoring fluid status One of the most sensitive indicators of patient volume status changes is their bodyweight. A nurse has an order to remove sutures from a client. 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.

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