A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?

Keep your environment well ventilated. This can help reduce nausea and vomiting by eliminating odors that might trigger them.

Some additional explanations are:

Choice B is wrong because eating three large meals each day can increase nausea and vomiting by overloading the stomach. It is better to eat small, frequent meals and avoid spicy, greasy, or strong-smelling foods.

Choice C is wrong because restricting intake of high-carbohydrate foods can lead to ketosis, which can worsen nausea and vomiting. High-carbohydrate foods can also help settle the stomach and provide energy.

Choice D is wrong because brushing your teeth immediately after eating can stimulate the gag reflex and cause nausea and vomiting. It is better to rinse your mouth with water or mouthwash after eating and brush your teeth at least an hour later.

Normal ranges for nausea and vomiting in pregnancy are:

• Nausea and vomiting usually start around 6 weeks of gestation and peak around 9 weeks. They usually subside by 16 to 20 weeks, but some women may experience them throughout pregnancy.
• Nausea and vomiting are considered mild if they do not interfere with daily activities or nutrition. They are considered moderate if they cause some difficulty with daily activities or nutrition. They are considered severe if they prevent adequate intake of fluids and nutrients, cause weight loss, dehydration, electrolyte imbalance, or ketonuria.
• Nausea and vomiting that are severe or persist beyond 20 weeks of gestation may indicate a complication such as hyperemesis gravidarum, molar pregnancy, multiple gestation, or infection.

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

• Blood pressure: less than 140/90 mmHg
• Heart rate: 60 to 100 beats per minute
• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation: greater than 95%
• Weight: stable or decreasing within 2 to 4 pounds per week