A nurse is caring for a client who is pregnant.
Exhibit 1
Nurses' Notes
1000:
The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.
1015:
IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.
1100:
Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.
1500:
Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.
Exhibit 2
Vital Signs
1000:
Temperature 36.8° C(98.2° F)
Heart rate 112/min
Respiratory rate 20/min
Blood pressure 100/65 mm Hg
SaO 97% on room air
1200:
Temperature 37° C(98.6° F)
Heart rate 102/min
Respiratory rate 20/min
Blood pressure 104/70 mm Hg
SaO2 98% on room air
1500:
Temperature 36.8° C(98.2° F)
Heart rate 90/min
Respiratory rate 18/min
Blood pressure 110/72 mm Hg
SaO2 97% on room air
For each discharge instruction, specify if each action is recommended or contraindicated for the client.
Alternate eating solid foods and liquids.
Eat every 2 to 3 hr.
Drink warm ginger ale when nauseated.
Increase intake of high-fat foods.
Recommended Contraindicated
Correct Answer : A,B,C,E
A. Recommended: Alternating between solids and liquids can help manage nausea and vomiting. It ensures that the stomach isn't overloaded and can help in maintaining hydration and nutritional intake. Drinking liquids between meals rather than with meals can prevent over-distension of the stomach, which may reduce nausea.
B. Recommended: Eating small, frequent meals helps keep the stomach from becoming too full or too empty, which can both trigger nausea. This practice ensures a steady supply of nutrients and calories, which is especially important during pregnancy.
C. Recommended: Ginger has properties that can help soothe nausea. Warm liquids are generally more tolerated than cold liquids.
D. High-fat foods are more difficult to digest and can slow gastric emptying, which may worsen nausea and vomiting. They can also increase the risk of acid reflux, which is common during pregnancy and can exacerbate nausea.
Recommended is correct. The nurse should indicate which actions are recommended for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. HD does not affect the eyes.
B. Incorrect. HD does not affect the respiratory system or cause chest manifestations.
C. Correct. Hirschsprung disease (HD) is a congenital disorder that affects the nerve cells in the colon, causing a lack of peristalsis and bowel obstruction. Infants with HD may have a distended abdomen due to fecal accumulation and gas.
Correct Answer is A
Explanation
A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.
D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
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