A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should include which of the following is an acceptable weight gain for this client?

The nurse should write an incident report for the following events:
1. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2. A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3. A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

The correct answer is choice b. “I will stop what I am doing and lie down.”

Choice A rationale:

Taking two 325 milligram aspirin tablets at the same time is not the recommended immediate action for chest pain. Aspirin can help in preventing blood clots, but it is not the first step in managing acute angina.

Choice B rationale:

Stopping activity and lying down is the correct initial response to chest pain. This helps reduce the heart’s workload and can alleviate the pain.

Choice C rationale:

Calling the provider after taking one dose of nitroglycerin is important, but it is not the first step. The client should first stop activity and lie down, then take nitroglycerin if prescribed.

Choice D rationale:

Holding the breath and bearing down (Valsalva maneuver) is not appropriate for managing chest pain and can actually increase the heart’s workload, potentially worsening the situation.