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A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the nurse that they did not notice any reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

A.

Notify the healthcare provider that the client may need a change in dosage.

B.

Auscultate the client’s bowel sounds and measure the abdominal girth.

C.

Advise the client that healing typically takes several weeks to occur.

D.

Confirm that the client is taking the medication one hour after meals.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Lansoprazole, a proton pump inhibitor (PPI), typically requires several weeks to achieve its full therapeutic effect. Notifying the healthcare provider for a dosage change after only one week is premature and not supported by clinical guidelines.

 

Choice B rationale

 

Auscultating bowel sounds and measuring abdominal girth are not directly related to the effectiveness of lansoprazole in treating GERD. These actions are more relevant for assessing gastrointestinal motility and potential complications like bowel obstruction.

 

Choice C rationale

 

Healing of erosive esophagitis with PPIs like lansoprazole usually takes several weeks. Advising the client that healing typically takes several weeks to occur is appropriate and aligns with the expected therapeutic timeline.

 

Choice D rationale

 

Lansoprazole should be taken before meals, not after, to maximize its effectiveness. Confirming that the client is taking the medication one hour after meals would not address the issue of symptom persistence.


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Correct Answer is B

Explanation

Choice A rationale

Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.

Choice B rationale

IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.

Choice C rationale

Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.

Choice D rationale

Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.

Correct Answer is A

Explanation

Choice A rationale

Suctioning to clear secretions from the airway is the first intervention to implement. The client’s weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise.

Choice B rationale

Offering a prescribed PRN analgesic is important for overall comfort but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice C rationale

Obtaining arterial blood gases may provide valuable information but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice D rationale

Administering a prescribed antipyretic is not the most immediate intervention needed to address the client’s respiratory distress.

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