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 is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.
B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.
C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.
D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.
Correct Answer is A
Explanation
A.This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.
B.While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.
C.While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.
D.Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.
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