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 {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Postpartum hemorrhage is incorrect because the client has scant lochia rubra and a firm fundus at the umbilicus, which indicate normal uterine involution and bleeding.
B. Seizures is correct because the client has signs of severe preeclampsia, such as headache, blurred vision, nausea, hyperreflexia, and clonus. These are indications of increased intracranial pressure and cerebral edema, which can lead to seizures or eclampsia.
C. Hyperglycemia is incorrect because there is no evidence of diabetes mellitus or gestational diabetes in the client's history or findings.
D. Hypoxemia is incorrect because there is no evidence of respiratory distress or impaired gas exchange in the client's history or findings.
E. Infection is incorrect because the client has no signs of infection, such as fever, malaise, foul-smelling lochia, or elevated WBC count.
Correct Answer is A
Explanation
A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
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