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A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Lie down after meals to reduce discomfort.
- B. Limit fluid intake to 1 liter per day.
- C. Avoid eating spicy foods.
- D. Eat three large meals each day.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.
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How should pain be assessed in a non-verbal patient?
- A. Observe facial expressions
- B. Use the Wong-Baker faces scale
- C. Assess heart rate
- D. Ask the patient to rate their pain
Correct Answer: A
Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.
How should fluid balance be monitored in a patient receiving diuretics?
- A. Monitor daily weight
- B. Monitor intake and output
- C. Check for edema
- D. Monitor blood pressure
Correct Answer: A
Rationale: Corrected Question: To assess fluid balance in a patient receiving diuretics, monitoring daily weight is the most accurate method. This is because diuretics primarily affect fluid levels in the body, leading to changes in weight due to fluid loss. While monitoring intake and output, checking for edema, and monitoring blood pressure are important aspects of patient care, they do not provide as direct and accurate information about fluid balance as daily weight monitoring specifically in patients on diuretics.
What is the most important nursing assessment post-surgery?
- A. Monitor vital signs
- B. Monitor blood pressure
- C. Monitor the surgical site
- D. Monitor the incision site
Correct Answer: A
Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.
A nurse is providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?
- A. This medication can be used to help you during an acute asthma attack.
- B. This medication helps decrease swelling and mucus production.
- C. This medication should be taken before exercise.
- D. This medication should be taken daily in the evening.
Correct Answer: D
Rationale: The correct answer is D. Montelukast should be taken daily in the evening for long-term control of asthma, rather than for immediate relief. Choice A is incorrect because montelukast is not used for acute asthma attacks. Choice B is incorrect as montelukast works by blocking leukotrienes, not by decreasing swelling and mucus production. Choice C is incorrect as montelukast is not specifically taken before exercise.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?
- A. Increase oxytocin infusion.
- B. Decrease oxytocin infusion.
- C. Maintain oxytocin infusion.
- D. Discontinue oxytocin infusion.
Correct Answer: D
Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.