A nurse is developing a plan of care for a client who has radiation-induced diarrhea and nausea. Which of the following interventions should the nurse include in the plan?
Provide a snack 30 min before treatments
Ensure foods are served hot
Administer antiemetics on a schedule
Serve low carbohydrate meals
The Correct Answer is C
Choice A reason: Providing a snack 30 min before treatments can worsen nausea and diarrhea, as food can stimulate gastric motility and secretion. It is better to avoid eating for at least 2 hours before and after treatments.
Choice B reason: Ensuring foods are served hot can increase nausea and diarrhea, as hot foods can have strong smells and irritate the digestive tract. It is better to serve foods at room temperature or cold.
Choice C reason: Administering antiemetics on a schedule can prevent nausea and vomiting, which can lead to dehydration and electrolyte imbalance. Antiemetics can also reduce abdominal cramps and spasms that cause diarrhea.
Choice D reason: Serving low carbohydrate meals can aggravate diarrhea, as carbohydrates are the main source of energy for the body. It is better to serve high carbohydrate meals that are easy to digest, such as rice, potatoes, bread, or crackers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
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.
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