Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching about disease management with a client who has GERD.
Which of the following statements should the nurse make?
A. "You should eat three large meals and two snacks per day."
"You should eat three large meals and two snacks per day" is not recommended for GERD management. Instead, it is advised to have smaller, more frequent meals throughout the day to reduce the pressure on the stomach and minimize the likelihood of acid reflux.
B. "You should lay down for 1 hour following a meal."
"You should lay down for 1 hour following a meal" is not recommended for GERD management. It is advised to avoid lying down immediately after meals, as this can increase the risk of acid reflux. It is generally recommended to wait at least 2 to 3 hours before lying down.
C. "You should elevate the head of the bed while sleeping."
Elevating the head of the bed while sleeping is a recommended strategy for managing GERD (gastroesophageal reflux disease). By raising the head of the bed, gravity helps to prevent stomach acid from flowing back into the esophagus, reducing the likelihood of acid reflux and associated symptoms.
D. "You should only drink 2 cups of coffee per day."
"You should only drink 2 cups of coffee per day" is a specific recommendation related to caffeine intake, which can potentially trigger or worsen GERD symptoms in some individuals. However, this statement alone does not encompass the comprehensive dietary recommendations for managing GERD.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
Elevating the head of the bed while sleeping is a recommended strategy for managing GERD (gastroesophageal reflux disease). By raising the head of the bed, gravity helps to prevent stomach acid from flowing back into the esophagus, reducing the likelihood of acid reflux and associated symptoms.
"You should eat three large meals and two snacks per day" is not recommended for GERD management. Instead, it is advised to have smaller, more frequent meals throughout the day to reduce the pressure on the stomach and minimize the likelihood of acid reflux.
"You should lay down for 1 hour following a meal" is not recommended for GERD management. It is advised to avoid lying down immediately after meals, as this can increase the risk of acid reflux. It is generally recommended to wait at least 2 to 3 hours before lying down.
"You should only drink 2 cups of coffee per day" is a specific recommendation related to caffeine intake, which can potentially trigger or worsen GERD symptoms in some individuals. However, this statement alone does not encompass the comprehensive dietary recommendations for managing GERD.
Similar Questions
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
A. Apply a warm compress.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
B. Document the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
C. Stop the infusion.
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
D. Elevate the arm.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
Full Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
A. “I will have a large scar on my stomach after this procedure."
This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.
B. "I am thankful I am done having children."
'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.
C. "I should expect my periods to resume in 1 month."
"I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.
D. "I will no longer need a regular gynecological examination."
"I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.
Full Explanation
Informed consent is a process where the healthcare provider explains the risks, benefits, and alternatives of a proposed procedure or treatment to the client. The client then demonstrates their understanding of this information and voluntarily agrees to undergo the procedure or treatment.
A. "I will have a large scar on my stomach after this procedure". This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.
B. 'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.
C. "I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.
D. "I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
A. Coil the tubing on the bed above the collection bag.
Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B. Instruct the client to hold the drainage bag at waist height when ambulating.
Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C. Secure the tubing with adhesive tape to the lower abdomen.
Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Collect a sterile specimen from the urinary drainage bag.
Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
Full Explanation
A. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.