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 A
Explanation
A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.
B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.
C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.
D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.
Correct Answer is A
Explanation
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
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