Question

A nurse is providing care for a client who has recently been diagnosed with acute gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

Answer 1

Correct Answers:

Avoiding aspirin therapy to treat pain or fever

Rationale :

🏵️ Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate and damage the gastric mucosa.

🏵️ Aspirin inhibits prostaglandin synthesis, reducing substances that normally help protect the stomach lining.

🏵️ Reduced prostaglandins decrease protective mucus and bicarbonate secretion and can impair mucosal blood flow.

🏵️ These effects can worsen gastric inflammation and exacerbate acute gastritis.

🏵️ Aspirin can also increase the risk of gastric erosion and gastrointestinal bleeding, especially when used frequently or in high doses.

🏵️ Clients with gastritis should avoid unnecessary aspirin and other gastric-irritating NSAIDs unless specifically prescribed.

🏵️ The client should discuss appropriate alternatives for pain or fever management with the health care provider.

🏵️ Therefore, teaching the client to avoid using aspirin for pain or fever can help prevent exacerbations of gastritis.

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Answer 2

Correct Answers:

Frequent anterior and posterior lung auscultation

Rationale :

🌹 The most significant potential complication of gastrostomy tube feeding in a client with late-stage Alzheimer disease is aspiration.

🌹 Advanced Alzheimer disease can impair swallowing, cough reflexes, airway protection, and level of functional awareness, increasing aspiration risk.

🌹 Gastric contents or enteral formula can reflux and enter the tracheobronchial tree, potentially causing aspiration pneumonia.

🌹 Frequent anterior and posterior lung auscultation helps the nurse detect changes such as new crackles or other abnormal breath sounds that can accompany respiratory complications.

🌹 Additional manifestations of aspiration include coughing, choking, tachypnea, dyspnea, fever, decreased oxygen saturation, and respiratory distress.

🌹 The nurse should reduce aspiration risk by maintaining the head of the bed at approximately 30° to 45° or higher during feeding, according to the feeding method and clinical situation.

🌹 The nurse should also monitor feeding tolerance, abdominal findings, tube position according to facility protocol, and respiratory status.

🌹 Therefore, frequent anterior and posterior lung auscultation directly addresses the highest-priority potential complication: aspiration and subsequent respiratory compromise.

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Answer 3

Correct Answers:

Maintain prescribed bowel rest and administer intravenous fluids as ordered

Rationale :

🧡 During acute diverticulitis, inflamed diverticula require decreased intestinal stimulation to reduce inflammation and prevent complications.

🧡 Bowel rest decreases colonic activity and allows the affected bowel to recover during the acute inflammatory phase.

🧡 Depending on severity, the client may initially be prescribed NPO status or clear liquids, with the diet advanced as symptoms improve.

🧡 Intravenous fluids maintain hydration and electrolyte balance when oral intake is restricted or when the client has nausea, vomiting, or fever.

🧡 Reducing bowel activity can help decrease abdominal pain and intestinal irritation during the acute episode.

🧡 Careful management is important because acute diverticulitis can progress to serious complications such as abscess, perforation, peritonitis, fistula, or bowel obstruction.

🧡 The nurse should monitor for worsening abdominal pain, rigidity, fever, tachycardia, and other signs of perforation or peritonitis.

🧡 Therefore, prescribed bowel rest with IV fluid therapy is appropriate during the acute phase.

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Answer 4

Correct Answers:

"I will drink less fluid throughout the day."

Rationale :

❣️ A client with a hiatal hernia does not routinely need to restrict overall daily fluid intake.

❣️ Adequate hydration remains important for normal gastrointestinal function and overall health.

❣️ Clients should instead avoid drinking large amounts of fluid with meals if this contributes to gastric distention or reflux.

❣️ Large meals and excessive gastric distention can increase pressure within the stomach and worsen gastroesophageal reflux.

❣️ Dietary management focuses on eating small, frequent meals and avoiding foods or beverages that trigger symptoms.

❣️ Common triggers can include caffeine, alcohol, chocolate, fatty foods, peppermint, and spicy foods, depending on individual tolerance.

❣️ Fluids can generally be consumed between meals to maintain adequate hydration without excessively distending the stomach during meals.

❣️ Therefore, stating that overall fluid intake should be reduced indicates a need for further teaching.

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Answer 5

Correct Answers:

Notify the provider immediately.

Rationale :

🖊️ Sudden severe abdominal pain, nausea, firmness, and inability to reduce the hernia are concerning for an incarcerated or strangulated hernia.

🖊️ An incarcerated hernia occurs when the protruding abdominal contents become trapped and cannot be returned to the abdominal cavity.

🖊️ Continued entrapment can compromise blood flow, resulting in strangulation and tissue ischemia.

🖊️ Strangulation can rapidly progress to bowel necrosis, perforation, peritonitis, sepsis, and shock if treatment is delayed.

🖊️ The nurse should therefore notify the provider immediately because urgent surgical evaluation may be necessary.

🖊️ The client should generally be kept NPO because emergency surgery might be required.

🖊️ The nurse should closely monitor vital signs, abdominal findings, pain, vomiting, bowel function, and manifestations of systemic deterioration.

🖊️ Prompt recognition and intervention are essential to preserve intestinal perfusion and prevent life-threatening complications.

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Answer 6

Correct Answers:

Erosion of the lining of the stomach or intestine

Rationale :

✳️ A peptic ulcer is an erosion or open sore that develops in the lining of the stomach or duodenum.

✳️ The ulcer forms when protective mucosal defenses are disrupted and gastric acid and pepsin damage the underlying tissue.

✳️ Common causes include Helicobacter pylori infection and long-term use of NSAIDs.

✳️ Peptic ulcers can occur in the stomach (gastric ulcer) or in the duodenum (duodenal ulcer).

✳️ Symptoms can include epigastric pain, nausea, bloating, and discomfort related to meals.

✳️ Complications can include bleeding, perforation, and gastric outlet obstruction.

✳️ Treatment focuses on reducing acid, treating H. pylori when present, and avoiding factors that damage the gastric mucosa.

✳️ Therefore, describing a peptic ulcer as an erosion of the lining of the stomach or intestine is accurate.

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Answer 7

Correct Answers:

Hang 10% Dextrose in water

Rationale :

🖊️ Total parenteral nutrition (TPN) contains a high concentration of dextrose, which causes the pancreas to maintain increased insulin secretion during the infusion.

🖊️ Abruptly stopping TPN can cause rebound hypoglycemia because circulating insulin can remain elevated after the concentrated glucose source is removed.

🖊️ When the next TPN bag is unavailable, the nurse should temporarily infuse 10% dextrose in water (D10W) at the prescribed/appropriate rate according to facility protocol.

🖊️ D10W supplies glucose while the replacement TPN solution is being obtained.

🖊️ This intervention helps maintain blood glucose stability and prevents an abrupt reduction in carbohydrate delivery.

🖊️ The nurse should monitor the client's blood glucose level, especially when TPN is interrupted or restarted.

🖊️ The nurse should also promptly contact the pharmacy or appropriate department to obtain the next TPN bag.

🖊️ Therefore, hanging D10W is the priority action when TPN unexpectedly becomes unavailable.

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Answer 8

Correct Answers:

Heart rate
Hct and Hgb
Neurological assessment

Rationale :

✳️ Heart rate — Requires Immediate Follow-Up

✳️ The client's heart rate increased from 108/min to 118/min, indicating worsening tachycardia.

✳️ In the setting of active GI bleeding, tachycardia can be an early compensatory response to decreased circulating blood volume.

✳️ The client's blood pressure is also falling, from 96/55 mm Hg to 90/55 mm Hg, which strengthens concern for evolving hypovolemia.

✳️ Ongoing blood loss can decrease venous return and cardiac output, prompting the heart to beat faster to maintain tissue perfusion.

✳️ Persistent tachycardia with hypotension can signal progression toward hypovolemic shock.

✳️ The nurse should closely monitor hemodynamic status and response to the prescribed IV fluid bolus.

✳️ Additional assessment should include skin temperature, capillary refill, level of consciousness, and evidence of continued bleeding.

✳️ Therefore, the rising heart rate requires immediate follow-up.

✳️ Hct and Hgb — Require Immediate Follow-Up

✳️ The client's Hgb is 10 g/dL and Hct is 30%, both below the expected ranges provided.

✳️ These findings support clinically significant blood loss and anemia in the setting of repeated episodes of bright-red GI bleeding.

✳️ Reduced hemoglobin decreases the blood's ability to carry oxygen to tissues.

✳️ The client's weakness, fatigue, dizziness, tachycardia, and hypotension are consistent with impaired oxygen delivery and decreased circulating volume.

✳️ Serial hemoglobin and hematocrit measurements may be needed because values can decline further as ongoing bleeding and fluid replacement alter the circulating volume.

✳️ Continued bleeding can eventually require blood product replacement or additional intervention, depending on severity and clinical response.

✳️ The nurse should monitor for worsening pallor, dyspnea, chest discomfort, altered mental status, and further hemodynamic instability.

✳️ Therefore, the decreased Hgb and Hct require prompt follow-up.

✳️ Neurological assessment — Requires Immediate Follow-Up

✳️ The client's neurological status has changed because ataxia was observed and the client reports being very dizzy.

✳️ Dizziness and impaired coordination can indicate decreased cerebral perfusion caused by hypovolemia and blood loss.

✳️ This is especially concerning because the symptoms are occurring alongside hypotension and worsening tachycardia.

✳️ A change in neurological status can be an early indicator that the body's compensatory mechanisms are no longer maintaining adequate brain perfusion.

✳️ The client is also at increased risk for falls and injury because of the ataxia and severe dizziness.

✳️ The nurse should maintain strict fall precautions and assist with all mobility.

✳️ Continued assessment should include level of consciousness, orientation, motor function, and progression of dizziness or weakness.

✳️ Therefore, the abnormal neurological assessment requires immediate follow-up.

❌ WBC count

✳️ The WBC count of 8,500/mm³ is within the expected range given.

✳️ There is no current laboratory evidence of significant infection or leukocytosis.

✳️ This finding does not take priority over active bleeding and compromised perfusion.

❌ Cardiac rhythm

✳️ The client has sinus tachycardia without dysrhythmias, so the rhythm itself is not the abnormal priority finding.

✳️ The important concern is the increasing rate associated with blood loss and hypovolemia.

✳️ Therefore, heart rate requires follow-up, while the documented rhythm remains expected.

❌ Urinary assessment

✳️ The client reports urinating without difficulty, and no abnormal urinary findings are documented.

✳️ Urine output should still be monitored because it can reflect renal perfusion during hypovolemia.

✳️ At present, the neurological changes, tachycardia, and reduced Hgb/Hct are more urgent.

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Answer 9

Correct Answers:

Encourage the client to use warm sitz baths 2-3 times a day.

Rationale :

🖊️ Warm sitz baths are an effective conservative intervention for relieving the pain and irritation associated with external hemorrhoids.

🖊️ Warm water promotes local vasodilation and relaxation of the anal sphincter, which can decrease discomfort and muscle spasm.

🖊️ Sitz baths also help reduce local swelling, itching, burning, and irritation around the anal area.

🖊️ The warm water gently cleanses the perianal region without the friction that can occur with vigorous wiping.

🖊️ A sitz bath can be particularly helpful after bowel movements, when hemorrhoidal pain and irritation may be greatest.

🖊️ The client should generally soak the affected area in warm, not excessively hot, water for about 10 to 15 minutes as directed.

🖊️ Additional management includes preventing constipation through adequate fiber, fluids, activity, and avoidance of straining during defecation.

🖊️ Therefore, using warm sitz baths 2–3 times daily can effectively reduce symptoms associated with external hemorrhoids.

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Answer 10

Correct Answers:

Sit in a semi-recumbent position after a meal.
Avoid drinking fluids while eating a meal.
Encourage to eat slowly and chew food well.
Eat meals that are low in simple carbohydrates.

Rationale :

🔅 Sit in a semi-recumbent position after a meal — Correct

🔅 Dumping syndrome occurs when gastric contents move too rapidly into the small intestine, commonly following gastric surgery.

🔅 Resting in a semi-recumbent or reclining position after meals can help slow gastric emptying.

🔅 Slower movement of food into the intestine reduces the sudden osmotic fluid shift responsible for many early dumping manifestations.

🔅 Early manifestations can include abdominal cramping, nausea, diarrhea, dizziness, tachycardia, and diaphoresis.

🔅 The client should avoid vigorous activity immediately after eating because activity can promote gastrointestinal motility.

🔅 A brief period of rest after meals can therefore reduce the severity of symptoms.

🔅 Avoid drinking fluids while eating a meal — Correct

🔅 Clients should generally avoid consuming significant amounts of fluid with meals because fluids can accelerate movement of gastric contents into the intestine.

🔅 Fluids are preferably consumed between meals, commonly separated from food by about 30 minutes or according to the prescribed nutrition plan.

🔅 Separating liquids from solid foods can help slow gastric emptying and reduce intestinal distention.

🔅 Adequate overall hydration should still be maintained throughout the day.

🔅 The client should not interpret this recommendation as fluid restriction.

🔅 The goal is to change the timing of fluid intake, not decrease total hydration.

🔅 Encourage eating slowly and chewing food well — Correct

🔅 Eating slowly helps prevent rapid delivery of large quantities of food into the gastrointestinal tract.

🔅 Thorough chewing improves mechanical digestion and supports better tolerance of meals.

🔅 Clients should eat in a calm environment and avoid rapid food consumption.

🔅 Small bites can also help the client regulate the amount of food consumed at one time.

🔅 These measures complement the recommendation for small, frequent meals.

🔅 Together, these strategies decrease the likelihood and severity of dumping manifestations.

🔅 Eat meals that are low in simple carbohydrates — Correct

🔅 Simple carbohydrates are rapidly absorbed and can create a high osmotic load in the small intestine.

🔅 Foods high in simple sugars can therefore worsen early dumping syndrome by promoting rapid fluid shifts into the intestinal lumen.

🔅 Rapid glucose absorption can also produce excessive insulin secretion, contributing to late dumping syndrome and reactive hypoglycemia.

🔅 Clients should limit foods such as candy, sugary beverages, syrups, cakes, and other concentrated sweets.

🔅 Meals generally emphasize protein, appropriate fats, and complex carbohydrates according to individual nutritional needs.

🔅 Reducing simple carbohydrates helps control both gastrointestinal and vasomotor manifestations of dumping syndrome.

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QLexNursing

1 :
A nurse is providing care for a client who has recently been diagnosed with acute gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

3 :
A nurse is caring for a client admitted with acute diverticulitis. Which intervention should the nurse include in the plan of care to reduce the risk for complications during the acute phase?

4 :
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which client statement indicates a need for further teaching?

5 :
A nurse is caring for a client with an abdominal hernia who suddenly reports severe abdominal pain and nausea. The hernia is firm and cannot be reduced. Which action should the nurse take first?

6 :
A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about their new diagnosis, how should the nurse best describe it?

7 :
A nurse notes that a client's total parenteral nutrition (TPN) bag will be empty in 30 minutes. and the next bag has not arrived, what is the nursing priority action?

8 :
A nurse in an emergency department is admitting a client.

Answer Options

9 :
A client with external haemorrhoids is experiencing pain and bleeding during bowel movements. Which intervention should the nurse include in the plan of care to reduce symptoms?

10 :
The nurse is providing education for a client at risk for developing dumping syndrome. Which instruction should the nurse include in the teaching? Select all that apply

QLexNursing

1 : A nurse is providing care for a client who has recently been diagnosed with acute gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

3 : A nurse is caring for a client admitted with acute diverticulitis. Which intervention should the nurse include in the plan of care to reduce the risk for complications during the acute phase?

4 : A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which client statement indicates a need for further teaching?

5 : A nurse is caring for a client with an abdominal hernia who suddenly reports severe abdominal pain and nausea. The hernia is firm and cannot be reduced. Which action should the nurse take first?

6 : A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about their new diagnosis, how should the nurse best describe it?

7 : A nurse notes that a client's total parenteral nutrition (TPN) bag will be empty in 30 minutes. and the next bag has not arrived, what is the nursing priority action?

8 : A nurse in an emergency department is admitting a client.

Answer Options

9 : A client with external haemorrhoids is experiencing pain and bleeding during bowel movements. Which intervention should the nurse include in the plan of care to reduce symptoms?

10 : The nurse is providing education for a client at risk for developing dumping syndrome. Which instruction should the nurse include in the teaching? Select all that apply

1 :
A nurse is providing care for a client who has recently been diagnosed with acute gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

3 :
A nurse is caring for a client admitted with acute diverticulitis. Which intervention should the nurse include in the plan of care to reduce the risk for complications during the acute phase?

4 :
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which client statement indicates a need for further teaching?

5 :
A nurse is caring for a client with an abdominal hernia who suddenly reports severe abdominal pain and nausea. The hernia is firm and cannot be reduced. Which action should the nurse take first?

6 :
A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about their new diagnosis, how should the nurse best describe it?

7 :
A nurse notes that a client's total parenteral nutrition (TPN) bag will be empty in 30 minutes. and the next bag has not arrived, what is the nursing priority action?

8 :
A nurse in an emergency department is admitting a client.

9 :
A client with external haemorrhoids is experiencing pain and bleeding during bowel movements. Which intervention should the nurse include in the plan of care to reduce symptoms?

10 :
The nurse is providing education for a client at risk for developing dumping syndrome. Which instruction should the nurse include in the teaching? Select all that apply