The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

A. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.

D. This response validates the client's feelings without making assumptions, allows the client to share more about their experience, and fosters a supportive environment. It's important for healthcare professionals to create a space where clients feel heard and understood, especially during times of grief and new diagnoses, which can be overwhelming.
A. It acknowledges the client's feelings while also expressing the nurse's understanding of the grieving process. It reassures the client that they are not alone in their experiences, even if the nurse hasn't experienced the exact situation. However, telling the client that you know what they are going through may not make them feel understood.
B. While this response acknowledges the client's grief, it may come across as minimizing or dismissive of their current emotional distress related to their diabetes diagnosis. It focuses solely on the loss of the spouse and doesn't address the client's immediate concerns about managing their newly diagnosed condition. Therefore, it may not be the most therapeutic response in this situation.
C. This response might unintentionally invalidate the client's feelings by suggesting they should distract themselves from their grief and diabetes diagnosis. It could be perceived as dismissive or insensitive, as it doesn't address the client's emotional needs or offer support. Additionally, suggesting distraction may not be helpful or appropriate for someone experiencing significant emotional distress.