A nurse is reinforcing teaching about disease management with client who has GERD. Which of the following statements should the nurse make?

"You should lay down for 1 hour following . meal."

"You should only drink 2 cups of coffee per day."

"You should elevate the head of the bed while sleeping."

"You should eat three large meals and two snacks per day."

Answer and Explanation

The Correct Answer is C

A) "You should lay down for 1 hour following a meal.":
Laying down after eating can exacerbate GERD symptoms by promoting acid reflux. The nurse should advise the client to remain upright for at least 30 minutes after eating to prevent reflux. Lying down increases the likelihood of gastric contents moving back into the esophagus.

B) "You should only drink 2 cups of coffee per day.":
Caffeine is a known trigger for GERD and can relax the lower esophageal sphincter, increasing the risk of acid reflux. The nurse should suggest limiting or avoiding coffee altogether, rather than recommending a specific quantity, as even small amounts may aggravate symptoms.

C) "You should elevate the head of the bed while sleeping.":
Elevating the head of the bed is a common and effective strategy for managing GERD. This helps prevent acid reflux during sleep by utilizing gravity to keep stomach contents from flowing back into the esophagus. A common recommendation is to elevate the head by 6-8 inches using blocks or a wedge pillow.

D) "You should eat three large meals and two snacks per day.":
Eating large meals can increase intra-abdominal pressure and promote acid reflux in clients with GERD. The nurse should recommend smaller, more frequent meals to reduce the risk of reflux and improve symptom control.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Administer phytonadione (Vitamin K): Contraindicated

There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.

Apply cool compress to the extremity: Anticipated

A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.

Elevate extremity: Anticipated

Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.

Suggest irrigating the IV catheter: Contraindicated

Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.

Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated

A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.

Send the catheter tip for culture: Anticipated

Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.

A. "You should expect to have blood work every 6 months while taking this medication." B. *You can safely take this medication if you become pregnant." C. "You might experience swollen gums while taking this medication." D. "You can skip a dose of this medication if you are nauseated."

Correct Answer is C

Explanation

A) "You should expect to have blood work every 6 months while taking this medication.": While it is important for clients on phenytoin to have regular blood work, especially to monitor drug levels and assess for potential side effects (e.g., liver function, complete blood count), the frequency of blood work is typically more frequent than every 6 months. Blood work is often performed at least every 3-6 months, or more frequently if there are concerns about phenytoin levels or side effects. Therefore, this statement is not accurate.

B) "You can safely take this medication if you become pregnant.": Phenytoin is classified as a Category D medication in pregnancy, meaning it has been shown to cause potential harm to the fetus. It is not considered safe during pregnancy, and women who are pregnant or planning to become pregnant should discuss alternative medications with their healthcare provider.

C) "You might experience swollen gums while taking this medication.": Gingival hyperplasia (swelling of the gums) is a common side effect of phenytoin. Clients taking this medication should be aware of this potential side effect and should be instructed on proper oral hygiene and regular dental checkups to help minimize this risk. This statement is accurate and should be included in the teaching.

D) "You can skip a dose of this medication if you are nauseated.": It is important not to skip doses of phenytoin, as maintaining therapeutic levels of the drug is crucial for its effectiveness in preventing seizures. If a client experiences nausea or difficulty taking the medication, they should contact their healthcare provider for guidance rather than skipping doses. Skipping doses could lead to breakthrough seizures.

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A nurse is reinforcing teaching about disease management with client who has GERD. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has pneumonia. For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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Correct Answer is C

Explanation

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