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 B
Explanation
Choice A rationale
Limiting fluid intake to 1500 mL/day is not recommended for bowel training. Adequate fluid intake is important for maintaining regular bowel movements and preventing constipation. Limiting fluids can worsen constipation and interfere with bowel training.
Choice B rationale
Assisting the client to the restroom 30 minutes after meals takes advantage of the gastrocolic reflex, which stimulates bowel movements following food intake. This helps establish a regular bowel routine and manage fecal incontinence.
Choice C rationale
Limiting physical activity is not advised for bowel continence. Regular physical activity promotes gastrointestinal motility and overall bowel health. Physical inactivity can lead to constipation and negatively impact bowel training efforts.
Choice D rationale
High-fiber foods are important for bowel health as they add bulk to stool and promote regular bowel movements. Limiting intake of high-fiber foods can lead to constipation and is counterproductive to bowel training.
Correct Answer is ["A","C"]
Explanation
Choice A rationale: Allergy to penicillin can be a contraindication for administering cefazolin because of potential cross-reactivity between penicillins and cephalosporins. This client’s documented allergy to penicillin with symptoms of rash and throat swelling is significant and raises concern for a potential allergic reaction to cefazolin.
Choice B rationale: Elevated WBC count indicates an ongoing infection or inflammation, which is not a contraindication for cefazolin. Instead, it suggests the need for an antibiotic like cefazolin to manage the infection.
Choice C rationale: Prescription for furosemide is relevant because combining cephalosporins like cefazolin with diuretics like furosemide can increase the risk of nephrotoxicity. It’s important to consider the client’s renal function and monitor for potential kidney damage.
Choice D rationale: Fever >38.3°C is an indication for antibiotic therapy, not a contraindication. The elevated temperature suggests an infection that needs to be treated, making cefazolin appropriate in this context.
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