Nokea
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Remain upright following meals.
- B. Avoid wearing tight fitting clothes.
- C. Minimize intake of spicy foods.
- D. Begin a smoking cessation program.
Correct Answer: A
Rationale: Remaining upright prevents gastric reflux by aiding stomach emptying, directly addressing GERD symptoms.
You may also like to solve these questions
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. Hemoglobin levels.
- B. White blood cell count.
- C. Red blood cell count.
- D. Platelet count.
Correct Answer: D
Rationale: Platelet count is directly related to petechiae and ecchymosis, indicating potential thrombocytopenia causing bleeding tendencies.
History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
- A. Administer additional nebulizer treatment as ordered.
- B. Take and monitor vital signs.
- C. Apply a nonrebreather oxygen mask.
- D. Increase oxygen flow.
- E. Raise the head of the bed.
- F. Provide client incentive spirometer and instruct on use.
Correct Answer: A,B,D,E
Rationale: Additional nebulizer treatment targets persistent wheezing, monitoring vital signs tracks response, increasing oxygen flow addresses low saturation, and raising the bed aids breathing. A nonrebreather is unnecessary at this stage, and incentive spirometry (F) is not indicated during an acute attack.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Uneven hair distribution.
- B. Lower leg edema.
- C. Bronze pigmentation.
- D. Bounding peripheral pulse.
Correct Answer: A
Rationale: Uneven hair distribution results from reduced blood flow impairing hair follicle nutrition, a sign of peripheral arterial disease.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Bring additional sterile dressing supplies to the room.
- B. Auscultate the abdomen for bowel sound activity.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Evisceration is a surgical emergency requiring immediate operative repair to prevent complications.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.