The nurse is providing care for a patient admitted for a lower respiratory infection. On admission, the patient's vital signs were blood pressure (BP) 140/80 mm Hg. apical pulse (AP) 112 beats/minute, respirations (R) 32 breaths/minute, and pain level of 8 on a scale of 0 to 10. After assisting the patient to bed and applying the prescribed oxygen, which finding helps the nurse evaluate the effectiveness of nursing care?

P 100 beats/minute

R 20 breaths/minute

BP 130/78 mm Hg

Pain level of 6/10

Answer and Explanation

The Correct Answer is B

B. A decrease in the respiratory rate from 32 breaths/minute to 20 breaths/minute indicates improved respiratory status and effectiveness of nursing care. A lower respiratory rate suggests that the patient's breathing is becoming less labored, and oxygenation may be improving.
A. A lower heart rate may suggest a reduction in pain, improved oxygenation, or decreased stress on the cardiovascular system. However, other factors such as medications, rest, and hydration can also influence heart rate. Overall, a decrease in heart rate is a favorable finding.
C. A slight decrease in blood pressure from 140/80 mm Hg to 130/78 mm Hg may indicate a positive response to nursing care. However, blood pressure fluctuations can be influenced by various factors, including hydration status, medications, and underlying medical conditions.
D. Pain management is an essential aspect of nursing care, particularly for patients with lower respiratory infections who may experience discomfort due to coughing, chest congestion, and inflammation. However, pain levels can fluctuate over time and may require ongoing assessment and intervention.

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Correct Answer is C

Explanation

C. Elevating the head of the bed can help reduce nighttime GERD symptoms. By elevating the head of the bed by about 6 to 8 inches (15 to 20 centimeters), gravity helps prevent stomach acid from refluxing into the esophagus while the individual is lying down. This position can alleviate symptoms such as heartburn, regurgitation, and coughing during sleep.
A. Alcohol consumption, especially before bedtime, can exacerbate GERD symptoms. Alcohol relaxes the lower esophageal sphincter (LES), allowing stomach acid to reflux into the esophagus more easily.
B. Sleeping on the stomach with the head flat can worsen GERD symptoms. This position can increase pressure on the stomach and promote reflux of stomach acid into the esophagus. Sleeping on the stomach is generally not recommended for individuals with GERD.
D. Eating a large meal or having a snack shortly before bedtime can increase the likelihood of GERD symptoms during sleep. It's generally recommended to avoid eating large meals or heavy snacks close to bedtime. Instead, individuals with GERD should aim to finish eating at least 2 to 3 hours before lying down to sleep.

A. Oatmeal with artificial sweetener, whole-grain toast, tea B. Two eggs two strips of bacon, orange juice, coffee C. One slice whole-grain toast with peanut butter, skim milk, orange juice D. One half grapefruit, cranberry juice, bagel with sugar-free jelly

Correct Answer is A

Explanation

A. Oatmeal is a good source of fiber, which can help manage blood sugar levels. Whole-grain toast provides complex carbohydrates and fiber, and using an artificial sweetener in oatmeal reduces sugar intake. Tea is a good beverage choice as it does not contain sugar or calories if not sweetened.
B. This option is less appropriate for a patient with diabetes. While eggs are a good source of protein, bacon is high in saturated fat and sodium, which is not ideal for cardiovascular health. Orange juice contains a high amount of natural sugar and can cause a rapid increase in blood glucose levels. Coffee is fine if consumed without sugar or high-fat creamers.
C. Whole-grain toast with peanut butter provides fiber, protein, and healthy fats, which are beneficial. Skim milk is a good source of calcium and protein. However, the inclusion of orange juice is problematic due to its high sugar content, which can spike blood sugar levels.

D. While grapefruit is a low-sugar fruit, cranberry juice often contains added sugars and can increase blood glucose levels. A bagel, even with sugar-free jelly, is high in refined carbohydrates, which can cause a rapid rise in blood sugar.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (GERD) about minimizing the effects of reflux during sleep. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

Which breakfast menu is most appropriate for a patient with diabetes?

Correct Answer is A

Explanation

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient has a BG value of 987 mg/dL. Which is the priority focus while providing care?

Which time would be ideal for the LPN/LVN to collect a sputum specimen?

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of gastroesophageal disease (GERD). Which of the following foods should the nurse include in the list of foods the client should avoid?

The patient with emphysema comes to the emergency department with difficulty breathing. What finding should the nurse anticipate during data collection? Select all that apply

A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

43. A nurse is reinforcing teaching about use of a metered-dose inhaler (MDI) with a client who has a new diagnosis of asthma. Identify the sequence the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)

After change of shift, the nurse has the following patients on her assignment. Which one should she see first?