The nurse is preparing a client for a clear-liquid breakfast who is weak from diarrhea and vomiting during the preceding night. Which does the nurse implement before assisting the client with feeding? (Select all that apply.)

Question

1. Assess the client's gag reflex.
2. Ask client to describe the emesis.
3. Assist the client with oral hygiene.
4. Remove bedpan and emesis basins.
5. Review food preferences for meals.
6. Offer a face cloth and hand washing.

Answer 1

3, 4, 5, 6
3. The nurse assists the client with oral hygiene before breakfast because refreshing the mouth increases food's appeal and refreshes the client. The mouth is likely to have residual film from the difficulties overnight and to be dry and sticky from fluid losses.
4. To increase enjoyment of the meal and removes potential offending odors, the nurse quietly removes the bedpan and emesis basin, closes the bathroom door, or pulls the commode out of the client's sight to help eliminate reminders of the recent unappetizing difficulties.
5. Reviewing food preferences is a good idea for the client troubled by vomiting and diarrhea during the night. If an unpleasant food is inadvertently served to the client, the food's smell or sight can trigger nausea and vomiting.
6. A face cloth and hand washing refresh the client and increase the client's potential enjoyment of the meal and the chances of the client retaining the food.
1. Assessing the gag reflex is not indicated.
2. Asking for a description of the emesis is unnecessary and likely to rekindle thoughts, along with unpleasant visions and smells, of the client's vomiting and di-arrhea.