A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?

 

Choice A rationale:

Metallic taste in mouth. Metallic taste in the mouth is a common side effect of many medications, including sertraline. It occurs due to the medication's effect on taste receptors. Patients should be informed about this side effect, but it is not a serious adverse effect that requires immediate medical attention.

Choice B rationale:

Increased urinary frequency. Increased urinary frequency is not a commonly reported side effect of sertraline. While some individuals may experience changes in urination patterns, it is not a significant adverse effect associated with this medication.

Choice C rationale:

Dry cough. Dry cough is not a known side effect of sertraline. Cough can occur due to various reasons, such as allergies, respiratory infections, or other medications, but it is not directly caused by sertraline.

Choice D rationale:

Excessive sweating. Excessive sweating, also known as hyperhidrosis, is a potential adverse effect of sertraline. It can be bothersome for some individuals and may impact their quality of life. Patients should be aware of this side effect and report it to their healthcare provider if it becomes bothersome or persistent.

Choice A rationale:

Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding. However, in this situation, the client is postpartum and unable to urinate, which might indicate a potential issue with the bladder or urethra. Performing a fundal massage would be more appropriate in this case as it helps to stimulate uterine contractions, which can aid in the expulsion of clots or retained placental fragments, potentially relieving the obstruction and allowing the client to urinate.

Choice B rationale:

Performing a fundal massage is the correct choice in this scenario. The nurse should gently massage the client's uterine fundus to promote uterine contractions. This can help expel clots or retained placental fragments, relieving any obstruction in the urethra and allowing the client to urinate. It's a standard practice after childbirth to prevent postpartum hemorrhage and ensure the uterus contracts properly.

Choice C rationale:

Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.

Choice D rationale:

Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.