Which nursing intervention is the most appropriate to implement for a client who experiencing weight loss due to nausea caused by chemotherapy?
Withhold solid foods and switch the client to liquid nutrition
Encourage the client to consume small, frequent meals throughout the day
Teach the client to eat one large meal per day to increase calorie intake
Insert a nasogastric tube and administer tube feedings
The Correct Answer is B
A. Automatically switching to liquid nutrition without assessing the client’s tolerance and needs may not be the most appropriate first step. It’s important to consider the client’s preferences, nutritional requirements, and overall ability to tolerate different types of food.
B. This is a highly appropriate and commonly recommended intervention for clients experiencing nausea and weight loss due to chemotherapy. Small, frequent meals can help manage nausea better than large meals and ensure a more consistent intake of calories and nutrients.
C. Eating one large meal per day is generally not advisable for clients with nausea, as it can exacerbate feelings of fullness and discomfort. Large meals may increase nausea and make it more difficult for the client to consume adequate nutrients. Small, frequent meals are generally better tolerated and more effective for managing nausea and ensuring consistent nutrient intake.
D. Inserting a nasogastric (NG) tube and administering tube feedings is a more invasive measure and is usually considered only if oral intake is severely compromised and other interventions have been ineffective. Tube feedings are appropriate for clients who cannot meet their nutritional needs through oral intake due to severe nausea, vomiting, or other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tachycardia (rapid heart rate) can occur in response to hypoxia (low oxygen levels), stress, or as a side effect of medications like albuterol. While tachycardia is a concerning sign in the context of an asthma exacerbation, it alone does not directly indicate the need for intubation and mechanical ventilation. It is often managed by addressing the underlying respiratory distress and improving oxygenation.
B. Anxiety is common in patients struggling to breathe, as they may feel frightened or panicked due to their difficulty breathing. However, anxiety itself is not an indicator for intubation and mechanical ventilation. It is a symptom of respiratory distress but does not directly assess the severity of the physiological need for mechanical support.
C. Hypotension (low blood pressure) in the context of an asthma exacerbation can be a sign of severe illness, possibly indicating shock or severe respiratory distress leading to reduced cardiac output. While hypotension is a serious concern, it is less directly related to the immediate need for intubation and mechanical ventilation compared to other indicators of respiratory failure.
D. Loud expiratory wheezing indicates significant airway obstruction but does not necessarily reflect the need for intubation and mechanical ventilation. Wheezing can be a sign of severe asthma but may not be sufficient on its own to necessitate intubation if the patient can still maintain adequate oxygenation and ventilation.
Correct Answer is D
Explanation
A. Hemoglobin levels measure the oxygen-carrying capacity of the blood. A reduced ejection fraction (30%) is more closely related to heart failure or significant cardiac dysfunction, which is not directly indicated by changes in hemoglobin levels.
B. Platelet levels are primarily involved in blood clotting and are less directly related to ejection fraction. Elevated or decreased platelet counts are not typically used as indicators of heart failure severity or reduced ejection fraction.
C. In cases of severe heart failure with a reduced ejection fraction, you may see elevated BUN levels due to these effects. However, it is not directly related to heart failure.
D. BNP is a hormone released by the heart in response to increased pressure and volume overload, typically seen in heart failure. Elevated BNP levels are associated with worsening heart failure and can be elevated in patients with a reduced ejection fraction. In heart failure, especially with an ejection fraction as low as 30%, BNP levels are often significantly elevated.
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