Nokea
A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the client?
- A. Avoid liquids unless a thickening agent is used
- B. Sit upright for at least 1 hour after eating
- C. Maintain a diet of soft foods and cooked vegetables
- D. Avoid eating 2 hours before going to sleep
Correct Answer: D
Rationale: Avoid eating 2 hours before going to sleep. Eating before sleeping enhances the regurgitation of stomach contents, which have increased acidity, into the esophagus. An upright posture should be maintained for about 2 hours after eating to allow for the stomach emptying. Options A and C are interventions for clients with swallowing difficulties.
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Which of the following is correct about DIC?
- A. It was once known as hemophilia A.
- B. It's both a bleeding and thrombotic disorder.
- C. It's clinically insignificant syndrome.
- D. It's never a complication of another condition.
Correct Answer: B
Rationale: DIC involves both clotting and bleeding due to widespread coagulation activation.
Based on this information, what condition appears to be developing?
- A. Neurogenic shock.
- B. Distribute shock.
- C. Septic shock
- D. Hypovolemic shock
Correct Answer: D
Rationale: Low blood pressure, tachycardia, and low urine output suggest hypovolemic shock, likely from postoperative bleeding.
Which one should be given priority?
- A. A 2-month-old with a sunken anterior fontanel.
- B. A 4-month-old with altered consciousness.
- C. A 6-month-old crying inconsolably.
- D. A 7-month-old who cannot hold his own bottle.
Correct Answer: B
Rationale: Altered consciousness in an infant is a critical sign requiring immediate assessment for neurological issues.
Which finding, if present, should the nurse interpret to mean that dialysis has achieved the desired results?
- A. The client weighs 5 lb more following dialysis.
- B. The client's blood pressure dropped during dialysis.
- C. The client produced 700 mL of urine in the first six hours after dialysis.
- D. The client's blood glucose is 98 mg/dL.
Correct Answer: B
Rationale: A drop in blood pressure indicates successful fluid removal during dialysis, a primary goal. Weight gain, urine output, or normal glucose are not direct indicators of dialysis efficacy.
The nurse notes all of the following. Which situation needs immediate attention?
- A. Dirty linen has fallen on the floor beside the bed of a bedridden client.
- B. Breakfast dishes remain on the overbed table two hours after mealtime.
- C. An elderly ambulatory client drops a glass of water on the floor beside the bed.
- D. The client's hi-low bed cannot be moved to the high position.
Correct Answer: C
Rationale: A water spill near an ambulatory client's bed poses an immediate fall risk, requiring prompt attention. Linen, dishes, or bed height are less urgent.