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What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?
- A. The patient should adjust their food intake to three full meals per day with no snacks.
- B. The patient should avoid participating in any aerobic exercise programs.
- C. The patient should sleep without pillows at night to maintain neck alignment.
- D. The patient should wear loose, comfortable clothing to minimize symptoms.
Correct Answer: D
Rationale: Wearing loose clothing reduces pressure on the abdomen, helping to minimize GERD symptoms by preventing reflux.
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The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
- A. Superficial partial-thickness.
- B. Full-thickness.
- C. Deep partial-thickness.
- D. Deep full-thickness.
Correct Answer: B
Rationale: A painless, brown/yellow, swollen burn indicates full-thickness damage, involving the epidermis and dermis.
Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?
- A. Keep the head of the bed elevated until the treatment is completed.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Monitor the client's intravenous site hourly during the treatment.
- D. Administer an antiemetic before starting the chemotherapy.
Correct Answer: C
Rationale: Hourly IV site monitoring allows early detection of extravasation, preventing tissue damage from vesicant chemotherapy.
The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan?
- A. The patient should eat a diet high in protein and vitamins A and C.
- B. The patient should keep their legs elevated when sitting or lying down.
- C. The patient should maintain as much bed rest as possible.
- D. The patient should inspect their ankles daily for areas of darkening skin.
- E. The patient should apply intermittent cold compresses four times daily.
Correct Answer: A,B,D
Rationale: A diet high in protein and vitamins A and C, leg elevation, and daily ankle inspections support healing and early detection of complications in venous leg ulcers.
A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
- A. Shoes should be worn outside the house, but it is fine to be barefoot inside.
- B. Family members can assist with regular foot exams.
- C. Heating pads are useful if used on the lowest setting.
- D. Aching feet may be soaked in lukewarm water for one hour or more.
Correct Answer: B
Rationale: Family members assisting with regular foot exams helps detect early signs of injury or infection, critical for preventing complications in diabetic neuropathy.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema.Concurrent and ascites in clients with cirrhosis?
- A. Decreased renin-angiotensin response related to an increase in renal blood flow.
- B. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
- C. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
- D. Decreased portacaval pressure with greater collateral circulation.
Correct Answer: B
Rationale: Hypoalbuminemia reduces oncotic pressure, causing fluid to leak into tissues and abdomen, leading to edema and ascites.