Nokea
The nurse caring for a client diagnosed with GERD writes the client problem of 'behavior modification.' Which intervention should be included for this problem?
- A. Teach the client to sleep with a foam wedge under the head.
- B. Encourage the client to decrease the amount of smoking.
- C. Instruct the client to take over-the-counter medication for relief of pain.
- D. Discuss the need to attend Alcoholics Anonymous to quit drinking.
Correct Answer: A
Rationale: Sleeping with a foam wedge elevates the head, reducing reflux by preventing stomach acid from flowing into the esophagus during sleep, a key behavioral modification for GERD. Smoking cessation is beneficial but less specific to immediate symptom relief, and the other options are not directly related to behavior modification for GERD.
You may also like to solve these questions
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
The nurse is assessing the client who is 24 hours post—GI hemorrhage. The findings include BUN of 40 mg/dL and serum creatinine of 0.8 mg/dL. Which action should be taken by the nurse?
- A. Immediately call the health care provider to report these results.
- B. Monitor urine output, as this may be a sign of kidney failure.
- C. Document the findings and continue to monitor the client.
- D. Encourage the client to limit his or her dietary protein intake.
Correct Answer: C
Rationale: A. No treatment is required; it is unnecessary to call the HCP. B. If acute kidney failure is present, both the BUN and creatinine would be elevated. C. The findings should be documented. The BUN can be elevated after a significant GI hemorrhage from the breakdown of blood proteins. The protein breakdown releases nitrogen that is then converted to urea. D. Limiting protein intake in the presence of healthy kidneys is unnecessary.
The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis?
- A. Eat a high-fiber diet.
- B. Increase fluid intake.
- C. Elevate the HOB after eating.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: A,B,D
Rationale: High-fiber diet, increased fluids, and regular exercise (e.g., walking) prevent constipation and reduce pressure in diverticula, lowering exacerbation risk. Elevating the HOB and antacids are unrelated to diverticulosis prevention.
The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?
- A. The client will not gain more than two (2) kg a day.
- B. The client will have no increase in abdominal girth.
- C. The client's vital signs will remain within normal limits.
- D. The client will receive a low-sodium diet.
Correct Answer: B
Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.
The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.