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A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
- A. I will lie on my left side to sleep at night.
- B. I will lie on my right side to sleep at night.
- C. I will sleep on my back with my head flat.
- D. I will sleep on my stomach with my head flat.
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the anatomical positioning of the stomach and esophagus. When lying on the left side, the stomach is positioned below the esophagus, reducing the likelihood of reflux.
Incorrect choices:
B: Lying on the right side can worsen reflux symptoms as it allows stomach acid to flow back into the esophagus more easily.
C: Sleeping on the back with the head flat may not be as effective in preventing reflux compared to the left side position.
D: Sleeping on the stomach with the head flat can exacerbate reflux symptoms by putting pressure on the stomach and pushing acid back up into the esophagus.
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A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Wound infection.
- B. Obesity.
- C. Altered mental status.
- D. Pain medication administration.
- E. Poor nutritional state.
Correct Answer: A,B,E
Rationale: The correct factors for dehiscence risk are wound infection, obesity, and poor nutritional state. Wound infection can delay healing and weaken tissue integrity, leading to dehiscence. Obesity puts extra strain on the incision site, increasing the likelihood of separation. Poor nutritional state impairs the body's ability to heal properly. Altered mental status and pain medication administration do not directly impact tissue integrity or healing process, thus are not significant risk factors for dehiscence.
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
- A. Check the circulation of the affected extremity.
- B. Administer additional pain medication.
- C. Reposition the affected extremity.
- D. Document the findings.
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (C) may worsen the condition if circulation is compromised. Documenting the findings (D) is important but not the priority when the client is experiencing severe unrelieved pain.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?
- A. 9 percent.
- B. 18 percent.
- C. 36 percent.
- D. 54 percent.
Correct Answer: B
Rationale: The correct answer is B (18 percent). The rule of nines is used to estimate the percentage of total body surface area (TBSA) affected by burns. According to this rule, each arm represents 9% of the TBSA (9% front + 9% back = 18%). Therefore, burns on both front and back of both arms would total 18% TBSA. Choices A, C, and D are incorrect because they do not accurately reflect the TBSA affected by burns on both arms. Choice A (9 percent) represents the TBSA of one arm, not both. Choices C (36 percent) and D (54 percent) overestimate the TBSA since they do not consider the rule of nines for the arms.