A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?
Raisin toast
Soft-serve ice cream
String cheese
Hot tea
The Correct Answer is A
A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.
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Correct Answer is D
Explanation
A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.
Correct Answer is C
Explanation
A. Delaying surgery in a life-threatening situation could endanger the client, so waiting for parental consent is not required under emergency circumstances.
B. The pediatrician does not have the authority to provide implied consent; this legal principle applies directly to the care team in emergency situations.
C. In emergency situations where a minor requires immediate, life-saving treatment and a parent or legal guardian is not available, implied consent allows the surgeon to proceed with necessary interventions to prevent harm.
D. An adult cousin does not have legal authority to provide consent for a minor’s treatment unless specifically designated as a legal guardian.