A nurse is caring for a patient with a history of gastroesophageal reflux disease (GERD). Which of the following interventions is most appropriate for this patient?

Correct Answer: B

Rationale: The correct answer is B: Advise the patient to sleep with the head of the bed elevated. Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus during sleep, reducing GERD symptoms. This position also promotes better digestion. Choices A, C, and D are incorrect because encouraging large meals before bedtime can worsen GERD symptoms, drinking caffeinated beverages can trigger acid reflux, and avoiding antacids can lead to inadequate symptom management.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis. Patients with a history of stroke are at an increased risk of developing deep vein thrombosis due to immobility and vascular damage. This complication can lead to serious consequences, such as pulmonary embolism. Monitoring for signs of deep vein thrombosis, such as leg swelling and pain, is crucial for early detection and intervention. Severe dehydration (A), liver failure (C), and pulmonary embolism (D) are less likely complications in a patient with a history of stroke compared to deep vein thrombosis.

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: D

Rationale: The correct answer is D: Hold the breath for at least 5 seconds after inhaling the medication. Holding the breath after inhaling the medication allows for better absorption of the medication into the lungs. This helps ensure the medication reaches the target area for optimal effectiveness. Exhaling deeply before using the inhaler (Choice A) is not necessary and can actually reduce the amount of medication reaching the lungs. Using the inhaler only when asthma symptoms are severe (Choice B) is not recommended as it is important to use the inhaler as prescribed by the healthcare provider. Inhaling deeply while activating the inhaler (Choice C) is important, but holding the breath after inhaling the medication is crucial for optimal medication delivery.