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 A
Explanation
A.Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.
B.While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.
C.Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.
D.While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily afinding that would prevent surgery.
Correct Answer is D
Explanation
Choice A reason:
Face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
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