Nokea
The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?
- A. I need to raise the head of my bed on blocks by at least 6 inches.
- B. I will remain sitting up for several hours after I eat any food.
- C. If my reflux and abdominal pain don’t improve, I might need surgery.
- D. Losing weight may reduce my reflux, so I plan to take a weight-lifting class.
Correct Answer: D
Rationale: Weight lifting can increase intra-abdominal pressure, worsening hiatal hernia symptoms, indicating a need for further teaching. Raising the bed, staying upright post-meals, and considering surgery for persistent symptoms are correct management strategies.
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A client is admitted with a possible gastric ulcer. Suddenly he calls to the nurse and says, 'It hurts so bad.' The client is pale and diaphoretic. What should the nurse do initially?
- A. Call the physician
- B. Touch the abdomen
- C. Obtain a stool for guaiac
- D. Place the client in a supine position
Correct Answer: A
Rationale: Sudden severe pain with pallor and diaphoresis suggests ulcer perforation, requiring immediate physician notification for urgent intervention.
The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
- A. flushing the suction catheter with 0.9% sodium chloride after each suction pass
- B. placing the client in the semi-Fowler position prior to suctioning
- C. applying intermittent suction while inserting the suction catheter
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct Answer: D
Rationale: A mild cold without fever does not contraindicate MMR vaccination. Pregnancy, immunocompromise, and neomycin allergy are contraindications due to live virus risks or anaphylaxis. Pharmacological Therapies
A young couple asks the nurse what method of contraception they should use. What information is most important for the nurse to have before giving an answer?
- A. The exact age of the couple
- B. The sexual history of both partners
- C. The method they find most acceptable
- D. How soon they want to start a family
Correct Answer: C
Rationale: The couple's preferred contraceptive method ensures adherence and satisfaction, guiding the nurse's recommendations. Age, sexual history, or family planning timeline are secondary.
The nurse is contributing to the plan of care for a newly admitted client with schizophrenia who is experiencing persecutory delusions. Which of the following interventions should the nurse suggest including in the client's plan of care?
- A. Explore the meaning behind the client's delusions
- B. Focus on the client's feelings related to the delusions
- C. Gently attempt to convince the client that the delusions are false
- D. Present the client with logical arguments to discredit the delusions
Correct Answer: B
Rationale: Focusing on the client's feelings related to delusions helps build trust and validates their emotional experience without reinforcing the delusion. Exploring meanings or challenging delusions directly can escalate distress or resistance, as delusions are fixed beliefs in schizophrenia.