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A nurse is caring for a client who is pregnant.

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.

The nurse is providing discharge teaching to the client.

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 actions

Answer and Explanation

Correct Answer : A,B,C,E

Correct answer: A, B, C, E

Rationale:

A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

- A. Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.

- B. Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.

- C. Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.

- D. Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.

A. Instruct the client to maintain a full bladder for the procedure. B. Administer a tocolytic 30 min before the procedure. C. Monitor the fetal heart rate throughout the procedure. D. Place the client in Trendelenburg position during the procedure.

Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.

Choice B rationale:

Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.

Choice C rationale:

Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.

Choice D rationale:

Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is planning care for a client prior to an amniocentesis.Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?