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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The nursing assistant reports that a client who is on a high-protein diet is eating only the fruits and vegetables on the meal tray. The nurse notes that the client is from the country of India. The nurse talks with the client. Which response by the nurse is likely to do most to help the client meet nutritional needs?
- A. Would you like a vegetarian diet?'
- B. Doesn't the food taste good?'
- C. What are your favorite foods?'
- D. It is important for your recovery that you eat the prescribed diet.'
Correct Answer: A
Rationale: Offering a vegetarian diet respects cultural preferences common in India, increasing adherence to nutritional needs. Asking about taste, favorite foods, or emphasizing the diet's importance is less effective.
The nurse is caring for a client with a history of chronic venous insufficiency. Which of the following interventions should the nurse prioritize?
- A. Apply warm compresses to the legs.
- B. Encourage leg elevation when sitting.
- C. Administer diuretics as ordered.
- D. Restrict ambulation to prevent swelling.
Correct Answer: B
Rationale: Leg elevation reduces venous pooling and edema in chronic venous insufficiency, improving circulation. Warm compresses (A) are inappropriate, diuretics (C) are not first-line, and restricting ambulation (D) worsens stasis.
Based on the admission assessment, the nurse will expect which drug will be ordered on the patient ASAP?
- A. Intal
- B. Ventolin
- C. Mucolytics
- D. Solumedrol IV
Correct Answer: B
Rationale: Ventolin (albuterol) is a bronchodilator, the first-line treatment for asthma exacerbation.
A client with mania is busy investigating the unit and overseeing the activities of others. She is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- A. Serve high-calorie foods she can carry with her.
- B. Encourage her appetite by sending out for her favorite foods.
- C. Serve her small, attractively arranged portions.
- D. Allow her in the unit kitchen for extra food whenever she pleases.
Correct Answer: A
Rationale: High-calorie, portable foods accommodate the client's high energy and distractibility, ensuring adequate nutrition. Other options are less practical or effective.
Which detail of a client's drug therapy is the nurse legally responsible for documenting?
- A. Peak concentration time of the drug
- B. Safe ranges of the drug
- C. Client's socioeconomic data
- D. Client's reaction to the drug
Correct Answer: D
Rationale: The nurse legally must document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data.