The nurse is planning to teach the patient with gastroesophageal reflux disease (GERD) about foods or beverages that decrease lower esophageal sphincter (LES) pressure. What should be included in this list (select all that apply)?

Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,

which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.

"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.

Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.

The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.

Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.

While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.