The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). Which instruction should the nurse give for management of this disease process?
Drink a carbonated beverage before bed
Increase fatty foods one at a time
Elevate the head of the bed when sleeping
Eat dinner late in the evening
The Correct Answer is C
Choice A reason: This is not a correct instruction because drinking a carbonated beverage before bed can worsen the reflux symptoms by increasing the gastric pressure and the production of gas.
Choice B reason: This is not a correct instruction because increasing fatty foods can worsen the reflux symptoms by delaying the gastric emptying and relaxing the lower esophageal sphincter (LES), which allows the stomach acid to flow back into the esophagus.
Choice C reason: This is a correct instruction because elevating the head of the bed when sleeping can help prevent the reflux symptoms by using gravity to keep the stomach contents from flowing back into the esophagus.
Choice D reason: This is not a correct instruction because eating dinner late in the evening can worsen the reflux symptoms by increasing the amount and acidity of the stomach contents, which can easily flow back into the esophagus when lying down. The client should avoid eating within 3 hours of bedtime.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sliced ham with green salad is not a good choice for a client who has diverticulitis. Diverticulitis is a condition where small pouches in the colon become inflamed or infected. The client should avoid foods that are high in fat, such as ham, or that contain seeds, nuts, or skins, such as green salad, as they can irritate the colon and worsen the symptoms.
Choice B reason: Pork tenderloin with green peas is not a suitable choice for a client who has diverticulitis. Pork tenderloin is a high-fat food that can increase the inflammation and pain in the colon. Green peas are also a source of fiber that can be hard to digest and can cause gas and bloating.
Choice C reason: Turkey sandwich with celery sticks is not an appropriate choice for a client who has diverticulitis. Turkey sandwich may contain mayonnaise, cheese, or other ingredients that are high in fat and can aggravate the condition. Celery sticks are high in fiber and have strings that can get trapped in the pouches and cause infection.
Choice D reason: Grilled chicken breast with white bread is the best choice for a client who has diverticulitis. Grilled chicken breast is a lean protein that can help the client heal and prevent malnutrition. White bread is a low-fiber food that can be easily digested and does not irritate the colon.
Correct Answer is A
Explanation
Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.
Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.
Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.
Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.
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