The nurse is considering the plan of care for this client.

Click to highlight the outcomes the nurse should include in this client's plan of care. Select all that apply.

Medications

Surgical solutions

Nutrition

Lifestyle

Endoscopic therapy

Answer and Explanation

Correct Answer : A,C,D

A. Pharmacologic therapy is a cornerstone of GERD management. The client was prescribed famotidine, an H2 receptor antagonist, which reduces gastric acid production and alleviates symptoms. Including medications in the plan of care ensures the nurse monitors effectiveness, educates the client on proper timing and dosing, and evaluates for side effects.

B. Surgery is generally reserved for clients with severe GERD, complications (e.g., strictures, Barrett’s esophagus), or those who do not respond to lifestyle modifications and medication therapy. The current presentation does not indicate the need for surgical intervention at this stage.

C. Dietary modifications are essential for symptom management in GERD. Recommendations include avoiding foods that trigger reflux (e.g., fatty or fried foods, chocolate, caffeine, spicy foods), eating smaller meals, and not lying down immediately after eating. Nutrition planning also helps address the client’s obesity, which is a risk factor for GERD.

D. Lifestyle interventions are critical in GERD management. These include weight reduction (the client has a BMI of 37.8 kg/m²), smoking cessation (the client smokes 1 pack per week), elevating the head of the bed, and avoiding tight clothing. These modifications can reduce symptom frequency and severity.

E. Endoscopic interventions are typically reserved for clients with complications or refractory GERD that does not respond to medications and lifestyle changes. There is no current indication for this client to undergo endoscopic therapy.

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Correct Answer is B

Explanation

A. Egg yolks are actually high in cholesterol, although they are a good source of protein and other nutrients. Telling the client they are low in cholesterol would be misleading.

B. Research shows that for most people, dietary cholesterol has a minimal effect on serum cholesterol levels. The body regulates cholesterol by adjusting endogenous production in the liver. Therefore, overly restricting cholesterol-containing foods, especially in a client with a BMI of 16 kg/m² (underweight), can contribute to nutrient deficiencies without significantly reducing heart disease risk. This education is especially important for clients who are underweight and need adequate nutrition for health.

C. While replacing saturated fats like butter with unsaturated fats such as vegetable oils is a healthy choice for lipid management, this does not address the client’s misunderstanding about the relationship between dietary cholesterol and blood cholesterol.

D. Whole milk actually contains more cholesterol and saturated fat than skim or low-fat milk. This statement could reinforce misinformation rather than correct it.

A. Educate client about the side effects of albuterol. B. Administer an anxiolytic. C. Obtain 12 lead electrocardiogram. D. Stop the albuterol administration and restart in 30 minutes.

Correct Answer is A

Explanation

A. This is the most appropriate action. Shakiness (tremor), tachycardia, and mild increases in blood pressure are common, expected side effects of albuterol, a beta-2 agonist. These effects usually resolve on their own and are not typically dangerous in otherwise stable clients. The nurse should provide reassurance and education, explaining that these symptoms are temporary and expected, while monitoring the client for more severe reactions.

B. Anxiolytics are unnecessary in this situation. The client’s symptoms are pharmacologic side effects of the medication, not anxiety. Administering an anxiolytic could mask symptoms and cause unnecessary sedation.

C. While tachycardia can sometimes warrant monitoring in clients with cardiac disease, in a client without known cardiac complications, the mild tachycardia from albuterol is usually benign and does not require immediate ECG assessment.

D. Stopping treatment is unnecessary unless the client develops severe adverse effects, such as significant chest pain, arrhythmia, or extreme shortness of breath. Interruption could compromise respiratory treatment for bronchospasm or asthma exacerbation.

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The nurse is considering the plan of care for this client. Click to highlight the outcomes the nurse should include in this client's plan of care. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who weighs 110 lb (50 kg) and has a body mass index (BMI) of 16 kg/m2 reports avoiding foods high in cholesterol to prevent the development of heart disease. Which information should the nurse provide to the client? Reference Range: Body mass index [18.0 to 24.9 kg/m2]

Correct Answer is B

Explanation

During the administration of albuterol per nebulizer, the client reports shakiness. The client's vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/88 mm Hg. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which tasks should the nurse delegate to the UAP? (Select all that apply)

For each potential nursing intervention, click to indicate whether it would be appropriate or not appropriate. Each row must have one response option selected.

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A client reports bloating and abdominal cramps after eating ice cream and foods with cheese. Which condition should the nurse suspect?

The nurse is caring for a client with acute osteomyelitis in the left lower extremity secondary to a traumatic foot injury. Which assessment should the nurse complete first?

The charge nurse in a critical care unit is reviewing client conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (140 to 180 g/L)]

The nurse is considering the plan of care for this client.

Click to highlight the outcomes the nurse should include in this client's plan of care. Select all that apply.