A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

Sleeping on a large wedge-style pillow

Eating dinner early in the evening

Drinking orange juice regularly

Consuming low-fat meats

Answer and Explanation

The Correct Answer is C

Gastroesophageal reflux disease (GERD) is a condition characterized by the backflow of stomach acid into the esophagus, causing symptoms such as heartburn. Orange juice is highly acidic, and consuming acidic foods and beverages can exacerbate the symptoms of GERD. The acidic nature of orange juice can irritate the esophagus and contribute to increased acid reflux, leading to heartburn.

Sleeping on a large wedge-style pillow can actually help alleviate symptoms of GERD by elevating the head and upper body, reducing the likelihood of acid reflux during sleep.

Eating dinner early in the evening is generally recommended for individuals with GERD as it allows sufficient time for digestion before lying down. This can help prevent acid reflux during sleep.

Consuming low-fat meats is also a favorable choice for individuals with GERD as fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. However, the options provided do not include any fatty foods, so it is not the primary contributing factor to the client's heartburn in this case.

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Correct Answer is ["1"]

Explanation

The nurse typically auscultates the abdomen for bowel sounds before meals or at least 1-2 hours after meals. This timing allows for the assessment of both the presence and character of bowel sounds. It is important to note that bowel sounds can vary depending on factors such as the client's activity level, diet, and any underlying gastrointestinal conditions. Therefore, a comprehensive assessment of bowel sounds should be conducted at different times to obtain an accurate representation of the client's bowel function.

A. Lower the height of the solution container. B. Stop the enema and document that the client did not tolerate the procedure. C. Encourage the client to bear down D. Allow the client to expel some fluid before continuing

Correct Answer is D

Explanation

When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.

The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:

Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.

Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.

Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.

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A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking the client's bowel sounds. At which time should the nurse auscultate the client's abdomen?

Correct Answer is ["1"]

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is D

Explanation

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