The nurse is continuing to assist in the care of the client.

Exhibits

The nurse should anticipate a provider prescription for

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and

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A. "I will increase vitamin C intake by drinking orange juice": This is incorrect because citrus juices like orange juice can exacerbate GERD symptoms by increasing acid production.
B. "I will lie down for 30 minutes after each meal": This is incorrect as lying down after eating can increase the risk of acid reflux. Clients should remain upright for at least 2-3 hours after eating.
C. "I will eat six small meals each day": This is correct because eating smaller, more frequent meals can help reduce the frequency of GERD symptoms by decreasing stomach pressure and acid production.
D. "I will sleep flat on my back at night": This is incorrect as sleeping flat can worsen GERD symptoms. Elevating the head of the bed can help prevent acid reflux during sleep.

A. Obtain vital signs every 5 min.

Rationale: The client's vital signs indicate hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). Frequent monitoring of vital signs is essential to assess changes in the client's condition and guide further interventions.

E. Initiate a second peripheral IV.

Rationale: Given the client's low urine output (110 mL over 6 hours) and signs of possible hypovolemia or fluid imbalance, establishing an additional IV line can facilitate the administration of fluids and medications more effectively.

F. Apply oxygen.

Rationale: The client's oxygen saturation is slightly decreased at 96% on room air. Applying supplemental oxygen can help improve oxygenation and alleviate symptoms related to decreased oxygen levels.

Not Recommended Actions:

B. Place the client in high-Fowler's position: This position might not be appropriate for a client with chest pain and potential hypovolemia, as it could exacerbate hypotension.

C. Perform gastric lavage: The output from the nasogastric tube (800 mL sanguineous) does not indicate a need for gastric lavage unless there is a specific reason to suspect gastrointestinal bleeding that requires immediate intervention.

D. Prepare to administer anticoagulants: There is no indication of thromboembolism or need for anticoagulants based on the provided information. The focus should be on addressing hypotension and fluid imbalance.