A nurse in a long-term care facility is providing care for a client who has gastroesophageal reflux (GERD). Which of the following interventions should the nurse implement?
A. Isolate the client in their room.
Encourage the client to ambulate with a staff member.
Administer a prescribed oral dose of trazodone to the client.
Apply bilateral wrist restraints to the client.
The Correct Answer is B
Choice A rationale
Isolating the client in their room is not necessary for managing GERD. Isolation measures are typically used for contagious diseases, not for GERD, which is a non-infectious condition.
Choice B rationale
Encouraging the client to ambulate with a staff member helps promote gastrointestinal motility and reduce the risk of reflux. Physical activity can aid in digestion and reduce GERD symptoms.
Choice C rationale
Trazodone is an antidepressant and is not typically prescribed for managing GERD. It is not relevant to the care plan for a client with GERD.
Choice D rationale
Applying bilateral wrist restraints is not indicated for GERD management. Restraints are used for patients who pose a risk to themselves or others, not for those with GERD. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Chlorhexidine is effective for disinfecting skin and mucous membranes, but it's not the best choice for cleaning blood spills. It is not as effective in breaking down organic material like blood.
Choice B rationale
Isopropyl alcohol is a good disinfectant for skin and surfaces but not ideal for cleaning large spills of blood, as it may not effectively neutralize all blood-borne pathogens. It also evaporates quickly, which limits its effectiveness on large spills.
Choice C rationale
Hydrogen peroxide can be used as a disinfectant and works well on small cuts or wounds. However, it is not the most effective for cleaning up blood spills because it is less effective against a broad range of pathogens.
Choice D rationale
Bleach is the recommended cleaning agent for blood spills because it effectively kills a wide range of pathogens, including HIV. A diluted bleach solution (usually 1 part bleach to 10 parts water) is effective in disinfecting areas contaminated with blood.
Correct Answer is A
Explanation
Choice A rationale
Aligning the client's joints with the joints on the CPM device frame ensures proper movement and prevents injury or discomfort. Correct alignment is crucial for effective therapy and to avoid strain on the joints.
Choice B rationale
High-Fowler's position is typically used for respiratory issues and does not align with the use of a CPM device for knee arthroplasty. Proper positioning is essential for the device's function.
Choice C rationale
Using a thick pillow to pad the CPM device could interfere with the device's movement and efficacy. Proper padding should ensure comfort without hindering the machine's operation.
Choice D rationale
Setting the degree of flexion and extension as tolerated by the client is important, but it should be done under medical guidance to ensure therapeutic benefits and avoid injury. Alignment is the primary concern.
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