A nurse is caring for a client who has nausea following radiation therapy. Which of the following interventions is appropriate for the nurse to take?
Offer the client frozen banana as a snack.
Serve the client hot meals.
Avoid serving sauces or gravies.
Discourage the use of a straw.
The Correct Answer is A
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help reduce nausea and stimulate appetite. Frozen banana is cold, bland, and easy to digest, which are characteristics of antiemetic foods. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
Correct Answer is D
Explanation
Choice A reason: Hemoglobin 16 g/dL is within the normal range for adults and does not indicate an adverse effect of TPN.
Choice B reason: Temperature 36.1°C (97°F) is normal and does not indicate an infection or inflammation, which are possible complications of TPN.
Choice C reason: Blood glucose 98 mg/dL is normal and does not indicate hyperglycemia or hypoglycemia, which are common problems associated with TPN.
Choice D reason: Weight gain of 1.5 kg (3 lB. per day is excessive and indicates fluid overload, which can result from too rapid or too high infusion of TPN. Fluid overload can cause edema, hypertension, heart failure, and pulmonary congestion.
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