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
An ecchymotic injection site indicates bruising, which can result from trauma or bleeding at the site but does not suggest a positive tuberculin skin test result. Positive results are based on induration, not discoloration.
Choice B rationale
A 15 mm induration at the injection site is considered a positive result for tuberculin skin test in any population. The size of the induration indicates a significant reaction to the tuberculin antigen, suggesting TB exposure.
Choice C rationale
A 3 mm induration is not considered a positive result for tuberculin skin test in any population. It indicates a minimal reaction that is below the threshold for positivity, suggesting no significant TB exposure.
Choice D rationale
A scabbed injection site indicates improper healing of the test site but does not correlate with a positive tuberculin skin test result. The presence of a scab does not indicate the size of the induration, which is the determining factor for test results. .
Correct Answer is A
Explanation
Choice A rationale
Hand hygiene is critical for preventing the spread of MRSA. Washing hands removes any bacteria that may have been picked up during contact with the infected client or surfaces in the room. Proper handwashing technique includes using soap and water or an alcohol-based hand sanitizer for at least 20 seconds.
Choice B rationale
Reusing unsoiled gloves is not recommended because MRSA can persist on surfaces and gloves for prolonged periods. Changing gloves each time entering the room ensures any contamination is not transferred to different areas or patients.
Choice C rationale
Wearing a gown protects the caregiver’s clothing from contamination when assisting with activities like bathing. Gowns act as a barrier to prevent MRSA from contacting the caregiver's skin or clothes and being carried outside the patient’s room.
Choice D rationale
Taking the client outside the room increases the risk of spreading MRSA to others. While a mask may protect against respiratory droplets, it does not prevent the transmission of MRSA via contact with contaminated surfaces or the patient’s skin.
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