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

Choice A rationale
Maintaining bed rest for 48 hours following surgery is a common practice to allow the body to heal and recover.
Choice B rationale

Irrigating the nasogastric tube every 4 to 8 hours is necessary to maintain patency and prevent blockage.
Choice C rationale
Encouraging hourly use of an incentive spirometer while awake can help prevent postoperative complications such as pneumonia and atelectasis.
Choice D rationale
Performing leg exercises every 2 hours is not typically included in the plan of care for a client who had surgery for a bowel obstruction and has a nasogastric tube in place.

• Increase fiber intake: This is nonessential at this time. While a high-fiber diet can help prevent future episodes of diverticulitis, it won’t help in the acute phase, especially when the client is unable to eat or drink without vomiting.
• CT of the abdomen with contrast: This is an anticipated action. A CT scan can help confirm the diagnosis of diverticulitis and assess the severity of the condition.
• Flexible sigmoidoscopy: This is an anticipated action. A flexible sigmoidoscopy can help visualize the diverticula and assess the extent of the inflammation.

• Change IV fluids to 0.9% sodium chloride with KCl: This is an anticipated action. The client is likely dehydrated due to vomiting and unable to take oral fluids, so IV hydration is necessary. The client’s potassium level is at the lower end of the normal range, so adding KCl to the IV fluids can help prevent hypokalemia.
• Type and crossmatch blood: This is an anticipated action. The client has a positive stool occult blood test and a lower than normal hemoglobin and hematocrit, suggesting that he may be experiencing bleeding. It’s important to have blood ready for a transfusion if necessary.
• Administer IV piperacillin-tazobactam: This is contraindicated. Piperacillin-tazobactam is a penicillin-based antibiotic, and the client has a known allergy to penicillin. Another class of antibiotics should be used. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.