Nokea
A client with gastroesophageal reflux disease (GERD) reports chest discomfort that feels like heartburn, especially following each meal. After teaching the client to take antacids as prescribed, the nurse suggests that the client lie in which position during sleep?
- A. Prone with the head of the bed flat
- B. Supine with the head of the bed flat
- C. On the left side with the head of the bed flat
- D. With the head of the bed elevated 8 to 12 inches
Correct Answer: D
Rationale: The discomfort of reflux is aggravated by positions that allow the reflux of gastrointestinal contents. The client is instructed to remain upright for 1 to 2 hours after a meal and sleep with the head of the bed elevated to approximately 30 degrees (usually on 8- to 12-inch blocks). Lying flat will increase the episodes of reflux, resulting in chest discomfort.
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The nurse is assessing a client with suspected dehydration. Which finding supports this diagnosis?
- A. Bounding pulse.
- B. Dry mucous membranes.
- C. Hypertension.
- D. Increased urine output.
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume in the body.
A client with a history of liver failure is prescribed lactulose (Cephulac). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased ammonia levels.
- B. Increased blood glucose.
- C. Decreased blood pressure.
- D. Increased platelet count.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels by promoting its excretion in hepatic encephalopathy.
A client at 37 weeks' gestation is scheduled for a biophysical profile. Which of the following should the nurse instruct the client to do before the test?
- A. Drink 1 to 2 L of fluid.
- B. Take nothing by mouth after midnight before the test.
- C. Plan to remain in the clinic for 4 hours after the test.
- D. Eat a high-fiber meal after the test.
Correct Answer: A
Rationale: Drinking 1-2 L of fluid ensures adequate amniotic fluid volume, which is assessed during a biophysical profile.
The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
- A. Assure that the oxygen is not blowing directly on the infant’s face.
- B. Place the butterfl y mobile on the outside of the hood.
- C. Immobilize the infant with restraints.
- D. Remove the hood for 10 minutes every hour.
- E. Encourage the parents to visit the child.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
A 36-month-old child weighing 44 lb is to receive ceftriaxone (Rocephin) 2 g I.V. every 12 hours. The recommended dose of Rocephin is 50 to 75 mg/kg/day in divided doses. The nurse should:
- A. Administer the medication as ordered.
- B. Administer half the ordered dose.
- C. Call the laboratory to check the therapeutic serum level of Rocephin.
- D. Withhold administering the Rocephin and notify the child's physician.
Correct Answer: D
Rationale: 44 lb = 20 kg. Recommended dose: 50-75 mg/kg/day = 1000-1500 mg/day. 2 g (2000 mg) every 12 hours = 4000 mg/day, exceeding the safe dose, so the nurse should notify the physician.