The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Choice A Reason:

Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.

Choice B Reason:

Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.

Choice C Reason:

Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.

Choice D Reason:

Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.

Choice A reason: Pee privacy

Ensuring privacy for a patient, especially one who is pregnant, is crucial. Privacy helps maintain the patient’s dignity and comfort during medical procedures. It also fosters a trusting relationship between the patient and the healthcare provider. In this context, “Pee privacy” likely refers to ensuring the patient has privacy when providing a urine sample, which is a common procedure during pregnancy check-ups to monitor for conditions like gestational diabetes or preeclampsia.

Choice B reason: Otoscope

An otoscope is a medical device used to look into the ears. While it is an essential tool in many medical examinations, it is not specifically related to the care of a pregnant patient unless there is a specific concern about ear health. Therefore, this choice is less relevant in the context of routine pregnancy care.

Choice C reason: Tannic acid

Tannic acid is a substance that can be used for various medical purposes, including treating burns and stopping bleeding. However, it is not typically associated with routine pregnancy care. Its inclusion in this list seems out of place unless there is a specific, unusual medical condition being addressed.

Choice D reason: Pupil dilation

Pupil dilation is a procedure often performed during eye examinations to allow a better view of the retina and other structures inside the eye. While important in ophthalmology, it is not a standard procedure in the care of a pregnant patient unless there is a specific concern about the patient’s vision or eye health.