Nokea
The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?
- A. Increase fluid intake with meals
- B. Avoid lying down for at least 30 minutes after eating
- C. Eat small, frequent meals throughout the day
- D. Consume spicy foods in moderation
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.
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A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?
- A. Auscultate breath sounds.
- B. Measure vital signs.
- C. Palpate the abdomen.
- D. Observe the skin for bruising.
Correct Answer: C
Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.
The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
- A. Platelet count and red blood cell count.
- B. White blood cell count and sputum culture.
- C. Hemoglobin A1c and glucose tolerance test.
- D. Arterial blood gases and serum electrolytes.
Correct Answer: B
Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.
An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. Administer the medication in 2 separate injections
- B. Give the medication in the dorsal gluteal site
- C. Call to get a smaller volume ordered
- D. Check with the pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.
A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?
- A. Monitor the site for further complications.
- B. Promptly remove the catheter from the radial artery.
- C. Elevate the client's arm above the heart.
- D. Notify the healthcare provider and prepare for surgery.
Correct Answer: B
Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.
A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?
- A. Monitor the client's liver function tests.
- B. Monitor the client's prothrombin time (PT).
- C. Monitor the client's partial thromboplastin time (PTT).
- D. Monitor the client's red blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.