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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Hypotension is not an adverse effect of epinephrine, but rather a sign of anaphylaxis that epinephrine can help to reverse by causing vasoconstriction and increasing blood pressure.
- B. Report of tinnitus is not an adverse effect of epinephrine, but rather a symptom of aspirin toxicity, which can occur in some clients who take aspirin for allergic reactions.
- C. Report of chest pain is an adverse effect of epinephrine, as it can cause cardiac dysrhythmias, angina, and myocardial ischemia by increasing the heart rate and oxygen demand of the myocardium.
-D. Ecchymosis is not an adverse effect of epinephrine, but rather a sign of bleeding disorders or trauma that can cause bruising under the skin.
Correct Answer is A
Explanation
- A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.
- B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.
- C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.
- D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.
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