Nokea
The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
- A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
- B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
- C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
- D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Correct Answer: D
Rationale: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.
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The client with hepatitis asks the nurse, 'I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?' Which statement is the nurse's best response?
- A. You are concerned about taking an herb.
- B. The herb has been used to treat liver disease.
- C. I would not take anything that is not prescribed.
- D. Why would you want to take any herbs?
Correct Answer: B
Rationale: Milk thistle is commonly used for liver support and may have hepatoprotective effects, though evidence is limited. This response provides accurate information without dismissing the client’s query.
The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.
The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
The nurse is developing a plan of care for the client with cirrhosis. Which intervention should be included in the client’s plan of care?
- A. Monitor the client’s blood sugar level.
- B. Place the client on NPO status.
- C. Administer antibiotics every 6 hours.
- D. Encourage ambulation every 4 hours.
Correct Answer: A
Rationale: A. The nurse should prepare to monitor the client’s blood sugar level. The client with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common with cirrhosis, and about 20% to 40% of clients also have diabetes. Hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. B. The client with cirrhosis would not be NPO but should receive a high-protein diet unless hepatic encephalopathy is present. C. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. D. The client with cirrhosis requires rest; thus, ambulation should not be encouraged every 4 hours.