A client has begun reporting nausea and vomiting.
What would the nurse assess to determine the need for therapy?
Number of times client’s family reports the client is nauseated.
How well the client is eating.
Color and amount of vomit, and frequency of vomiting episodes.
Client’s nutritional status and fluid balance.
The Correct Answer is C
The nurse would assess these factors to determine the need for therapy. Some possible explanations for the other choices are:
Choice A. Number of times client’s family reports the client is nauseated.
This is not a reliable indicator of the severity or cause of nausea and vomiting.
The nurse should assess the client directly and not rely on the family’s reports.
Choice B. How well the client is eating.
This is not a specific or objective measure of nausea and vomiting.
The client may have other reasons for not eating well, such as loss of appetite, taste changes, or pain.
The nurse should also monitor the client’s weight, hydration status, and electrolyte levels.
Choice D. Client’s nutritional status and fluid balance.
These are important aspects of the client’s overall health, but they are not directly related to nausea and vomiting.
The nurse should assess these factors as part of the comprehensive care plan, but they are not sufficient to determine the need for therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement indicates that the patient understands the common side effect of codeine and how to prevent accidents while taking it.
Choice A is wrong because the patient should not take the medication anytime he starts to cough, but only as prescribed by the doctor.
Taking too much codeine can lead to overdose, addiction, or respiratory depression.
Choice B is wrong because this medication may not make the patient anxious and nervous, but rather sedated and relaxed.
Anxiety and nervousness are more likely to occur with decongestants, which are stimulants.
Choice D is wrong because diarrhea is not a common side effect of codeine.
In fact, codeine may cause constipation, so the patient should increase fluid and fiber intake while taking it.
Correct Answer is D
Explanation
Glargine is a long-acting insulin that can provide a steady level of insulin for up to 24 hours. This would be suitable for a client who does not want to administer insulin on the plane, as they would only need one injection per day.
Choice A. Aspart is wrong because aspart is a rapid-acting insulin that has a peak effect within 1 to 3 hours and lasts for 3 to 5 hours.
This would require frequent injections and monitoring of blood glucose levels.
Choice B. Lispro is wrong because lispro is also a rapid-acting insulin that has a similar onset and duration as aspart.
It would not provide adequate coverage for a long international flight.
Choice C. Glulisine is wrong because glulisine is another rapid-acting insulin that has an onset of 15 minutes and a duration of 2 to 4 hours.
It would also require multiple injections and frequent blood glucose checks.
Normal ranges for blood glucose levels are 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
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