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A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should lay down for 1 hour following a meal.
- B. You should eat three large meals and two snacks per day.
- C. You should only drink 2 cups of coffee per day.
- D. You should elevate the head of the bed while sleeping.
Correct Answer: D
Rationale: Elevating the bed head prevents acid reflux at night. Lying down post-meal, large meals, or coffee can worsen GERD symptoms.
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A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can take aspirin for a headache.
- B. I might need to have my blood tested regularly.
- C. I should increase my intake of green leafy vegetables.
- D. I can stop taking this medication once my clot dissolves.
Correct Answer: B
Rationale: Warfarin requires regular INR monitoring to ensure therapeutic levels. Aspirin increases bleeding risk, leafy greens affect efficacy, and stopping risks recurrence.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which of the following actions should the nurse take?
- A. Infuse the blood over 6 hr.
- B. Check the client's temperature every 30 min.
- C. Administer the blood through a 22-gauge IV catheter.
- D. Flush the IV line with dextrose 5% in water before infusion.
Correct Answer: B
Rationale: Monitoring temperature every 30 minutes detects transfusion reactions early. Blood infuses over 2-4 hours, requires a large-gauge catheter, and saline, not dextrose, is used.
A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
- A. Urine output of 300 ml over 8 hr.
- B. Occasional small clots in the urine
- C. Dark red urine
- D. Frequent urge to urinate
Correct Answer: C
Rationale: Dark red urine may indicate hemorrhage, a serious complication requiring immediate reporting. Urine output of 300 mL over 8 hours is adequate, small clots are expected, and frequent urge to urinate is common post-procedure.