A nurse is caring for a client who is pregnant.

Exhibit 1

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.

1500:

Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

Exhibit 2

Vital Signs

1000:

Temperature 36.8° C(98.2° F)

Heart rate 112/min

Respiratory rate 20/min

Blood pressure 100/65 mm Hg

SaO 97% on room air

1200:

Temperature 37° C(98.6° F)

Heart rate 102/min

Respiratory rate 20/min

Blood pressure 104/70 mm Hg

SaO2 98% on room air

1500:

Temperature 36.8° C(98.2° F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 110/72 mm Hg

SaO2 97% on room air

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 Contraindicated

Answer and Explanation

Correct Answer : A,B,C,E

A. Recommended: Alternating between solids and liquids can help manage nausea and vomiting. It ensures that the stomach isn't overloaded and can help in maintaining hydration and nutritional intake. Drinking liquids between meals rather than with meals can prevent over-distension of the stomach, which may reduce nausea.

B. Recommended: Eating small, frequent meals helps keep the stomach from becoming too full or too empty, which can both trigger nausea. This practice ensures a steady supply of nutrients and calories, which is especially important during pregnancy.

C. Recommended: Ginger has properties that can help soothe nausea. Warm liquids are generally more tolerated than cold liquids.

D. High-fat foods are more difficult to digest and can slow gastric emptying, which may worsen nausea and vomiting. They can also increase the risk of acid reflux, which is common during pregnancy and can exacerbate nausea.

Recommended is correct. The nurse should indicate which actions are recommended for the client.

Nursing Test Bank

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Correct Answer is A

Explanation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

A. Encourage the client to take a cool sponge bath each morning. B. Administer opioid analgesia. C. Increase the client's dietary iron intake. D. Restrict the client's intake of foods high in purines.

Correct Answer is C

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

Correct Answer is A

Explanation

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Correct Answer is C

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