Nokea
Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
- A. Teach the client to elevate the head of the bed on blocks
- B. Remind the client to avoid high-fiber foods
- C. Encourage the client to lie down and rest after meals
- D. Instruct the client to use antacids only as a last resort
Correct Answer: A
Rationale: Elevating the head of the bed on blocks helps reduce reflux of stomach acid into the esophagus, improving symptoms of gastroesophageal reflux disease.
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All of the following are part of acute aortic syndrome, except
- A. Aortic dissection
- B. Acute aortic regurgitation
- C. Intramural hematoma
- D. Penetrating atherosclerotic ulcer
Correct Answer: B
Rationale: Acute aortic regurgitation is not typically considered part of acute aortic syndrome.
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
- A. Clamp the catheter for 30 minutes prior to irrigating with saline
- B. Manually irrigate the catheter with sterile saline as prescribed
- C. Increase the client's oral fluid intake to flush out clots naturally
- D. Remove the catheter and notify the healthcare provider immediately
Correct Answer: A
Rationale: Clamping the catheter before irrigation prevents sudden fluid shifts and ensures that irrigation is performed effectively.
An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
Regarding resuscitation of a three-year old with asystole:
- A. Hypoxia is the commonest cause
- B. It commonly leads to ventricular fibrillation
- C. Intracardiac adrenaline is an absolute indication
- D. IV calcium gluconate is the first line of therapy
Correct Answer: A
Rationale: Hypoxia is the most common cause of asystole in children, emphasizing the importance of oxygenation during resuscitation.
Drugs to be avoided in renal failure include:
- A. Allopurinol
- B. Digoxin
- C. Ceftazidime
- D. Acyclovir
Correct Answer: B
Rationale: Digoxin is avoided in renal failure due to its narrow therapeutic index and renal excretion, which can lead to toxicity.