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