100% ATI COMPREHENSIVE PREDICTOR RETAKE COMPREHENSIVE STUDY GUIDE 100% CORRECTALREADY GRADE +TRUST AND CONFIDENCE

100% ATI COMPREHENSIVE PREDICTOR RETAKE COMPREHENSIVE STUDY GUIDE 100% CORRECTALREADY GRADE +TRUST AND CONFIDENCE clinical findings of malnutrition poor wound healing dry hair irregular blood pressure weak hand impaired coordination how is BMI classified healthy weight= 18.5-24.9 over weight= 25-29.9 obese= greater than or equal to 30 negative nitrogen balance using protein faster than protein is being synthesized example starvation or catabolic State Post injury or disease risk factors for developing osteoporosis family history inactivity cigarette smoking to avoid complications of enteral feeding such as diarrhea cramping abdominal distension dumping syndrome nausea or vomiting what are your nursing actions diarrhea=decrease the flow rate or total volume of the infusion abdominal distention/bloating= instill lower fat formula consider changing the formula instill lactose free formula= nausea&vomitting administer enteral nutrition at room temperature to avoid complications of enteral feeding such as misplacement dislodgement aspiration irritation and leakage irritation of the nose esophagus and clogging of the feeding tube what are your nursing actions confirm to placement prior to feedings Elevate head of bed 30 degrees maintain position up for 60 mins flush tubing with 15-30 of warm water Q 4 hours unclog tubing with gentle pressure 32 -50 ml warm water and piston syringe to avoid complications of enteral feeding such as dehydration hyperglycemia electrolyte imbalance fluid overload refeeding syndrome or rapid weight gain what are your nursing actionsh restrict fluids if fluid overload monitor electrolytes serum glucose and weights monitor respiratory cardiovascular and neurological status provide water change formula to isotonic phenytoin carbamazepine valproic acid Gabapentin meds used for seizures if a client is taking phenytoin what should a nurse include in the teaching taking medication at the same time everyday to enhance effectiveness nursing care for phenytoin good oral hygiene side effect gingival hyperplasia schedule routine Dental visits avoid oral contraceptives they decrease effectiveness when administer does Warfarin and can cause decrease in effectiveness notify provider patient over-the-counter meds use vagul nerve stimulatorj implanted left chest program to administer instrument that stimulation of the brain via vagal nerve patient teaching for vagal nerve stimulator can cause temporary hoarseness cough dyspnea and change your voice nursing care assist with safe feeding for a patient who has a stroke consult speech language pathologist assess swallowing and gag reflex before feeding upright position swallow with head and neck flex slightly forward food is placed in the back of the mouth on the unaffected side have suction on standby collaborate with a dietician to ensure appropriate caloric intake weight loss is common following stroke nursing actions for patient who had a stroke or has dysphagia cheap and patient NPO position upright High Fowler's position prior to food fluid or Med Administration patient teaching for dysphagia and aspiration set up right in Flex head forward when swallowing sit upright for 45 to 60 Minutes following a meal what type of precaution should a patient with tuberculosis be on airborne precautions negative air-flow room patient wear surgical masks if being transported what is mantoux test diagnostic procedure for tuberculosis read within 48 to 72 hours palpable Rays Harden area of 10 mm or greater is positive skin test means patient has developed immune response to TB does not confirm active disease is present what are the nursing actions for isoniazid monitor for hepatotoxicity jaundice anorexia malaise fatigue nausea and neurotoxicity tingling of hands and feet vitamin B6 prevents neurotoxicity monitor liver function lab tests before and monthly after what is the patient teaching for taking isoniazid take on an empty stomach do not drink alcohol it can increase pepper toxicity report any manifestations of hepatotoxicity what is the nursing action for rifampim is there an app for hepatitis hepatotoxicity monitor liver function lab test prior to and at least monthly after patient teaching while taking Rifampin urine and secretions will turn orange immediate you leave report yellow skin pain or swelling of joints loss of appetite or malaise Med can interfere with oral contraceptives efficiency what is the nursing action for ethambutol get Baseline vi visual Acuity test incomplete monthly determine color discrimination ability should not be given to children under 8 years of age stop immediately if ocular toxicity occurs what is the patient teaching for ethambutol report changes in Vision immediately describe interprofessional care for a client who has TB contact Social Services if patient needs assistance getting meds refer a patient to a clinic as needed for follow-up appointments to monitor my medication regimen and status of disease tuberculosis discharge teaching TB usually treated in the home airborne precautions not needed in the home families have already been exposed continue meds for 6 to 12 months follow up care one full year sputum samples needed every 2 to 4 weeks patients are no longer considered infectious after 3 negative sputum cultures patients to cover mouth and nose when coughing or sneezing dispose of tissues and plastic bags wear mask when in public or in contact with crowds what is the nursing action for pyrazinamide absorbed for hepatotoxicity monitor patients who have history of gout as the med will cause gouty arthralgias obtain liver enzymes at Baseline and every two weeks what is the patient teaching for taking pyrazinamide drink glass of water with each juice and increase fluids during the day to prevent gout and kidney problems immediately report yellow skin pain of joints loss of appetite or malaise avoid alcohol nursing action for compartment syndrome assess capillary refill distal to graft prepare a patient for a fasciotomy to relieve pressure priority medication for angina nitroglycerin which is a Vaso dilator reduces preload and afterload used cautiously with other antihypertensive meds can cause orthostatic hypotension patient teaching for chest pain stop activity and rest Place nitroglycerin tablet under tongue let dissolve if pain. unrelieved in 5 minutes call 911 or have someone drive to ER patient can take two more doses at five minute intervals headache is common change position slowly if a patient has heart failure pulmonary edema as a nurse what are your interventions daily weight and I&O'S administer O2 as prescribed monitor shortness of breath and dyspnea on exertion position High Fowler's check abg's electrolytes monitor digoxin toxicity encourage bed rest until patient is stable fluid restriction sodium restriction what meds will be used for a patient who has heart failure or pulmonary edema Loop Diuretics= furosemide bumetanide thiazide diuretics = hydrochlorothiazide potassium sparing diuretics= spironalactone loop and thiazide can cause hypokalemia pt drink and eat foods high in potassium ace inhibitors side effects and nursing action dry cough angioedema swelling of tongue and throat decreased sense of taste or skin rash nurse monitor for hypotension monitor increase levels of potassium monitor BP 2 hours after initial dose expected manifestations of dehydration tachycardia hypotension orthostatic hypotension decreased central venous pressure dizziness syncope confusion weakness fatigue thirst dry furrowed tongue nausea vomiting anorexia weight loss decrease production and concentration of urine diminished capillary refill cool clammy skin diaphoresis sunken eyeballs flat and neck veins poor skin turgor and tenting weight loss. low grade fever Cholecystitis and cholelithiasis dietary teaching reduce dairy products fried foods chocolate nuts gravies avoid beans cabbage cauliflower broccoli take vitamins to Aid with