When developing a plan of care for a patient with altered ...

[cdr_15]

When developing a plan of care for a patient with altered nutritional needs, the nurse must assess the patient for which of the following? (Select all that apply.)
 
  a. What is the condition now?
  b. Is the condition stable?
  c. Will the condition get worse?
  d. Will the disease process accelerate deterioration?
  e. Which single objective measure will predict the course of action?

Question 2

The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. The nurse plans to include which of the following interventions in the client's care?
 
  a. Assess nares for skin breakdown every six hours.
  b. Check patency of the cannula every two hours.
  c. Inspect the mouth every six hours.
  d. Check oxygen flow every 24 hours.

[xiazhe]

Answer to Question 1

A, B, C, D
Nutritional screening tools must gather data based on four main principles: What is the condition now? Is the condition stable? Will the condition get worse? And will the disease process accelerate nutritional deterioration? Using a single objective measure is ineffective in predicting risk of nutritional problems.

Answer to Question 2

A
The nurse caring for the client with a nasal cannula should plan to assess the client's nares and superior surface of both ears for skin breakdown every six hours.
The nurse should check patency of the cannula every eight hours; he or she should not need to check q2h.
The nurse does not need to check the client's mouth in relation to the client's use of a nasal can-nula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures.
Oxygen flow should be monitored continuously, not every 24 hours.

[cdr_15]

TYSM

[Jsherida]

Gracias!