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 D
Explanation
A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
Correct Answer is A
Explanation
A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.
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