ATI
Whats the intake breakfast - 4 oz juice 6 oz hot tea voided 450 after breakfast IV bolus of 150 mL @ 0900 100 mL of ice chips before lunch Lunch- 8 oz broth vomited 120 mL and voided 600 mL JP emptied 40 mL
4 x 30 mL/oz + 6 x 30 mL/oz + 150 mL + 100 mL + 8 x 30 mL/ oz = answer: 790 mL
A nurse is helping an older client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker the nurse should:
answer: Check that the client lifts the walker then places it down in front of her (the client should lift the walker and advance it about 6 inches, then set it down. This allows her a wide base of support while she moves forward) other rationales: -as the client is ambulating the nurse should walk slightly behind her and toward her side in case she needs assistance -the client should move the walker first, then move one foot up to the walker while bearing weight on the other foot and both arms, then move the other foot forward with the weight on the first foot and both arms - the height of properly fitted walker should be just below the level of the clients waist. She should stand in the center of the walker and grasp the hand grips on either side, with her elbows bent at about 30 degrees
a nurse is reinforcing home safety info to an older adult client. what indicates a need for further instruction
answer: I should use a handrail instead of my cane when going downstairs (Indicates for further teaching. When going down stairs the client should use the handrail AND the cane. The client should hold firmly to the handrail and place the cane on the first stair, leaving room for feet. The weaker leg should be placed on the first stair, after which the client should step down with the good leg. The procedure should be continued all while holding firmly to the handrail as the client progresses down the staircase.) rationales: -I should have grab bars installed in my bathroom - grab bars placed near toilets and in the tub/shower area minimize the likelihood of a fall. Older adults frequently have issues when lowering or rising from a toilet seat or stepping into the tub/ shower due to arthritis. Bc of this the client may get off- balanced and fall. Water in the tub/ shower further increase risk of falls. Grab bars increase safety for older adults. - I should leave a nightlight on when i retire for the night - at night, a lit path to the bathroom minimizes falls. This is an important safety issue as falls are responsible for significant injury in home accidents -i should have the batteries charged in my smoke detector twice a year - climbing is required to reach a smoke detector. Climbing puts the patient at risk for a fall so it is advisable for the client to have someone else change the batteries. smoke detectors are the first line of defense for surviving a home fire. smoke detectors may be tied into the home electrical system with a battery back up or be only battery operated. Its recommended that the batteries be changed when the time changes in the spring and fall to ensure battery life is current
a nurse is caring for a client who came to the ED with abdominal distention and is now on the med surg unit with an NG in place to low gastric suction. The client is reporting anxiety, discomfort. and feeling bloated. Which of the following is the nurse's priority action?
answer: check to see if the suction equipment is working - the first action the nurse should take is using the nursing process to collect data and ASSESS. The nurse should check for the most obvious reason why the clients symptoms have returned. If suction equipment has malfunctioned, there is no need for the nurse to do anything else except adjust it or replace it with working equipment rationales: -request a prescription for a medication to ease the clients anxiety- it might become necessary to request an anti-anxiety med for the client at some point, but this is not the first action the nurse should take -irrigate the NG tube with 100 mL of sterile water - it might become necessary but this is not the first action - remove and reinsert NG - it might become necessary but this is not the first action
A nurse is caring for a client with a new dx of diabetes mellitus type 1. Which of the following is an appropriate teaching intervention that focuses on affective learning?
answer: explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on AFFECTIVE learning) rationales: -ask the client to perform a return demonstration of insulin injections - this teaching focuses on psycho motor learning -review the action of insulin therapy - this teaching focuses on cognitive learning -have a family member practice BG monitoring using a glucometer- this teaching intervention focuses on psycho motor learning
a nurse is teaching a new group of AP about the importance of hand hygiene. which of the following statements should the nurse include
answer: hand hygiene is crucial in preventing the spread of germs - hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either nurse or the client may have micro orgs. on their body that dont harm them but harm others
a nurse is preparing to administer opthalmic solution to a client. which of the following is an appropriate action by the nurse
answer: hold solution 2 cm (3/4 inc) above the lower conjunctival sac rationales: - instill the drops into the inner canthus -the drops are instilled into the center of the upper conjunctival sac - instill the drops into the center of the upper
a nurse is caring for a pt who frequently attempts to remove his feeding tube. the family requests restraints. which of the following statements by the nurse is appropriate
answer: i will move the tube so he cannot see it. (moving the tube so it is not within the clients visual field is an appropriate distraction technique) rationale: -let me increase the stimulation in his environment - decreasing stimuli in the environment can reduce a clients agitation and confusion -i will call the doctor and get the order - alternative interventions should be attempted before applying a restraint - lets wait until tonight to see if he continues this behavior - due to client safety concerns the nurse should not delay addressing the situation
a nurse is caring for an older adult client who has left sided weakness/ which of the following formation regarding the use of a cane is appropriate
answer: place the cane on the right side, and advance the left foot fwd rationales: - hold the cane with the left hand - the cane should be placed on the stronger side of the body. for this client the cane should be held with the right hand - advance the cane forward 35-45 cm (12-18 inches) with each step - the nurse should have the client keep the cane on the stronger side of the body. For max support when walking, the client should place the cane forward 15-25 cm (6-10 inc) keeping body weight on both legs - move the right leg forward first when using the cane - the cane should be placed on the stronger side of the body (held with the right hand). the weaker leg (left) should be advanced towards the cane. The stronger leg (right) is then advanced forward past the cane
a nurse is providing palliative care to a client whose partner asks why music therapy has been recommended. appropriate responses:
answers: - music therapy can help her verbally express emotions - music therapy works as a distraction and can help alleviate her pain - music therapy can help facilitate mvmt in some clients who have mobility limitations
the nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. which of the following indicates a therapeutic response
the shoulder drop- a back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. the relaxation of drooping of the shoulders would be a positive response the facial muscles relax- " " The pulse is within normal range- " "