A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

Provide three large meals a day.

Observe stool characteristics.

Evaluate intake and output.

Monitor laboratory reports of electrolytes.

Answer and Explanation

The Correct Answer is A

Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.

Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inﬂammation in the gastrointestinal tract, evaluating intake and output can help to identify any ﬂuid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.

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Correct Answer is D

Explanation

One of the hallmarks of adrenal insufficiency is dehydration and decreased urinary output, which can lead to electrolyte imbalances such as hyperkalemia and hyponatremia. As treatment begins to take eﬀect, the patient's ﬂuid and electrolyte balance should improve, leading to an increase in urinary output. Acute adrenal insufficiency, also known as the Addisonian crisis, is a life-threatening condition caused by a sudden decrease in cortisol and aldosterone hormones. Treatment usually involves the administration of intravenous glucocorticoids and mineralocorticoids to replace the deficient hormones.
Decreasing serum sodium (a) and decreasing blood glucose (b) are not signs of improvement but rather indicative of continued adrenal insufficiency. Decreasing serum potassium (c) is also not a sign of improvement as it could indicate that the patient is developing hyperkalemia, which is a potential complication of adrenal crisis.

A. Schedule for IVP. B. Draw blood for blood urea nitrogen (BUN) and creatinine. C. Insert 16 French retention catheter. D. Administer lorazepam (Ativan) 0.5 mg.

Correct Answer is C

Explanation

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

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A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

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