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?
Administer a bronchodilator after meals.
Ambulate the client before each meal.
Limit fluid intake with meals.
Offer the client three large meals each day.
The Correct Answer is C
The correct answer is choice c. Limit fluid intake with meals.
Choice A rationale:
Administering a bronchodilator after meals is not ideal because bronchodilators are typically given before meals to help open the airways and make breathing easier during eating.
Choice B rationale:
Ambulating the client before each meal might cause fatigue, making it harder for the client to eat and potentially decreasing their overall intake.
Choice C rationale:
Limiting fluid intake with meals can help prevent the client from feeling too full, which can make it easier for them to consume more solid food. This is particularly important for clients with COPD who may already have a reduced appetite and difficulty eating large amounts at once.
Choice D rationale:
Offering three large meals each day is not recommended for clients with COPD. Smaller, more frequent meals are generally better tolerated and can help prevent the feeling of fullness that can make breathing more difficult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Avoid preparing medications for more than two clients at one time is a guideline aimed at reducing the risk of medication errors. However, it is not an absolute rule and may vary depending on the setting and resources available.
Choice B reason: Inform clients about the action of each medication prior to administration. This practice is essential for patient education, ensuring that patients are informed about what medications they are taking and why, which can improve adherence and outcomes.
Choice C reason: Reading medication labels at least two times prior to administration is a good practice to avoid errors, but it is not always specified as a standard requirement in medication administration guidelines.
Choice D reason: Completing an incident report if a client vomits after taking a medication is necessary only if the vomiting is related to an adverse drug reaction or a medication error, not for routine vomiting.
Correct Answer is B
Explanation
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
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