Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream.
Suggest that the client also plan to eat frequent small meals to reduce discomfort.
Remind the client that it is also important to switch to decaffeinated coffee and tea.
Reinforce the teaching by asking the client to make a list of snack foods high in dairy content.
The Correct Answer is A
Choice A rationale
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.
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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.
Correct Answer is C
Explanation
Choice A rationale
Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. The type of dressing used is more important for managing the wound.
Choice B rationale
Leaving the dressing off until consulting with the healthcare provider is not recommended as it can expose the wound to infection and delay healing.
Choice C rationale
Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with significant granulation. Hydrocolloidal dressings provide a moist environment that promotes healing and protects the wound from contamination.
Choice D rationale
Replacing the gauze with a transparent dressing may not provide the necessary moisture and protection for a stage 3 pressure injury. Hydrocolloidal dressings are more suitable for this type of wound.