Chapter 45: Caring for Clients with Disorders of the Upper Gastrointestinal Tract

Question: Which of the following is the most common type of diverticulum? Answer: Zenker's diverticulum

Explanation: The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

Question: An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? Answer: Palpate the client's parotid glands to detect swelling and tenderness.

Explanation: Older adults and debilitated clients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

Question: The nurse is caring for a client who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed? Answer: 1 1/2 to 3 months

Explanation: An alternative to the PEG device is a low-profile gastrostomy device (LPGD). LPGDs may be inserted 6 weeks to 3 months after initial gastrostomy tube placement.

Question: The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the Answer: potential risk for aspiration.

Explanation Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Question: A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? Answer: A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.

Explanation: A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II.

Question: Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? Answer: Chancre

Explanation: A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.

Question: A client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition? Answer: Impaired ability to absorb food

Explanation: A client with Crohn's disease will have an impaired ability to ingest or absorb food orally or enterally. Clients with severe burns, malnutrition, short-bowel syndrome, AIDS, sepsis, and cancer would need parenteral nutrition because of insufficient oral intake. Unwillingness to ingest nutrients orally would cause a client with a major psychiatric illness to need parenteral nutrition. Prolonged surgical nutritional needs such as what occurs after extensive bowel surgery or acute pancreatitis would necessitate the need for parenteral nutrition.

Question: A client diagnosed with a peptic ulcer says, "Now I have something else I have to worry about." Which actions will the nurse take to help reduce the client's anxiety? Select all that apply. Answer: 1. Offer information about relaxation methods. 2. Help identify the client's current stressors. 3. Interact with the client in a relaxed manner. 4. Discuss potential coping techniques with the client.

Explanation: A client with a peptic ulcer may have a problem with anxiety. To help reduce the client's anxiety, the nurse should interact with the client in a relaxed manner and help the client identify stressors. The nurse can also discuss potential coping techniques and offer information about relaxation methods. Stating that medication will solve the problem may not be sufficient if stress and anxiety are contributors to the development of the ulcer.

Question: A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? Answer: Acute gastritis

Explanation: A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.

Question: A client was treated in the emergency department after ingesting bleach. Which possible complication(s) of the resulting gastritis will the nurse monitor for? Select all that apply. Answer: 1. Esophageal obstruction related to scarring 2. Pyloric obstruction related to scarring

Explanation: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in esophageal and/or pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a client who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

Question: A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) Answer: 1. It can be caused by ingestion of strong acids 2. You may have ingested some irritating food 3. Is it possible that you are overusing aspirin

Explanation: Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate.

Question: The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? Answer: When the residual is greater than 200 mL

Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.

Question: The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of Answer: organic fruit juice.

Explanation: Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Clients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.

Question: The nurse is caring for a young woman who is struggling with weight loss issues, without apparent physical cause. Which is the most likely nursing assessment for this nutritional disorder in which normal body weight is not maintained? Answer: Anorexia nervosa

Explanation: Anorexia nervosa is a nutritional disorder that is characterized by a refusal to maintain normal body weight in the absence of physical cause. Anorexia nervosa is considered a psychiatric disorder in a relentless pursuit of thinness. Bulimia is an eating disorder in which voracious appetite is followed by purging and is most likely found in normal to overweight individuals. Kwashiorkor is a severe protein deficiency associated with lack of protein in the diet. Crohn's disease can result in nutritional deficiencies but has apparent physiological cause.

Question: A client with a diagnosis of late-stage Alzheimer disease has begun supplemental feedings through a nasogastric (NG) tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? Answer: Frequent lung auscultation

Explanation: Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the client's cognitive deficits. Consequently, the nurse should auscultate the client's lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the client's abdominal girth is not a main focus of assessment.

Question: The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? Answer: Avoiding taking aspirin to treat pain or fever

Explanation: Aspirin and other NSAIDs are implicated in chronic gastritis because of their irritating effect on the gastric mucosa. Organic foods and vitamins confer no protection. Exercise and a healthy body weight are beneficial to overall health but do not prevent gastritis.

Question: A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? Answer: Imbalanced Nutrition: Less Than Body Requirements

Explanation: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a person's nutritional status. Dental caries do not typically affect the client's tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

Question: The most significant complication related to continuous tube feedings is Answer: the increased potential for aspiration

Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Question: The most significant complication related to continuous tube feedings is Answer: the increased potential for aspiration.

Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Question: The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the Answer: potential risk for aspiration

Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Question: A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make? Answer: It aids in the healing of the stomach lining.

Explanation: Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum.

Question: A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Answer: Nystatin

Explanation: Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

Question: The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? Answer: Peptic Ulcers

Explanation: Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

Question: Which ulcer is associated with extensive burn injury? Answer: Curling ulcer

Explanation: Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

Question: Cancer of the esophagus is most often diagnosed by which of the following? Answer: Esophagogastroduodenoscopy (EGD) with biopsy and brushings

Explanation: Currently, diagnosis is confirmed most often by EGD with biopsy and brushings. The biopsy can be used to determine the presence of disease and cell differentiation. X-ray, barium swallow, and fluoroscopy are used in the diagnosis of hiatal hernia.

Question: The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? Answer: 6

Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

Question: A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? Answer: Slows gastric emptying

Explanation: Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.

Question: A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event? Answer: Dumping syndrome

Explanation: Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that occur in up to 76% of patients who have had bariatric surgery. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. These symptoms resolve once the intestine has been evacuated (i.e., with defecation).

Question: Which of the following actions is most likely to effectively assess the level of anxiety a client diagnosed with gastric cancer is experiencing? Answer: The client is encouraged to express fears openly.

Explanation: Encouraging the client to discuss his or her fears and anxieties is usually the best way to assess a client's anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some clients, but it is not an assessment.

Question: A client presents to the clinic reporting vomiting and burning in the mid-epigastrium. Which causative factor will the nurse identify may be the cause of these symptoms? Answer: Infection with Helicobacter pylori

Explanation: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acid-base imbalances do not cause peptic ulcer disease.

Question: A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? Answer: Insertion is likely to cause some gagging.

Explanation: Insertion may cause gagging until the tube has passed beyond the throat. Insertion is often unpleasant, but not normally painful. Anesthetic is not usually applied and there is no initial need for a small-gauge tube.

Question: A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries? Answer: Inadequate nutrition and decreased saliva production can cause cavities

Explanation: Many ill clients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the client is not significant in the development of dental caries in the ill client.

Question: A client with gastric ulcers caused by H. pylori is prescribed metronidazole. Which client statement indicates to the nurse that teaching about this medication was effective? Answer: It might cause a metallic taste in my mouth.

Explanation: Metronidazole is a synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when given with other antibiotics and proton pump inhibitors. This medication may cause a metallic taste in the mouth. It should not be taken with anticoagulants as it will increase the blood thinning effects of warfarin. Alcohol should be avoided while taking this medication. This medication may cause anorexia and not an increased appetite.

Question: A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? Answer: Infection typically occurs due to ingestion of contaminated food and water.

Explanation: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to all areas of the United States. Genetic factors have not been identified.

Question: A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Answer: Gastroesophageal reflux disease

Explanation: Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.

Question: A client being treated for a peptic ulcer seeks medical attention for vomiting blood. Which statement indicates to the nurse the reason for the client developing hematemesis? Answer: The pain stopped so I stopped taking the medications.

Explanation: The client should be instructed to adhere to and complete the medication regimen to ensure complete healing of the peptic ulcer. Because most clients become symptom free within a week, it should be stressed to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of symptoms can be prevented. Since the client stopped taking the medication, the ulcer was not healed and became worse. The statements about soda, being nauseated, and eating only one meal would not explain the reason for the client's new onset of hematemesis during treatment for a peptic ulcer.

Question: The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client? Answer: Eat several small meals daily spaced at equal intervals.

Explanation: The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms.

Question: During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take? Answer: Notify the primary health care provider.

Explanation: The client with peptic ulcer disease is demonstrating signs of hemorrhage which include cool skin and tachycardia. The health care provider should be immediately notified. The client should not be given any additional medication. A warm beverage could enhance bleeding. It is inappropriate to provide any teaching while the client is experiencing an acute condition.

Question: Which term refers to the first portion of the small intestine? Answer: Duodenum

Explanation: The duodenum is the first portion of the small intestine, between the stomach and the jejunum. The pylorus is the opening between the stomach and duodenum. The peritoneum is the thin membrane that lines the inside the wall of the abdomen and covers all the abdominal organs. The omentum is the fold of the peritoneum that surrounds the stomach and other organs of the abdomen.

Question: The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? Answer: metoclopramide

Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

Question: The nurse provides health teaching to inform the client with oral cancer that Answer:

Explanation: The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.

Question: The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? Answer: Hematemesis

Explanation: The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria.

Question: The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? Answer: Notify the physician

Explanation: The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.

Question: Which of the following is the most successful treatment for gastric cancer? Answer: Removal of the tumor

Explanation: There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.

Question: A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Answer: Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

Explanation: To minimize the risk of aspiration, it is important to place the client in a semi-Fowler position during, and 60 minutes after, an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.

Question: The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? Answer: Diagnosed with malabsorption syndrome

Explanation: Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.

Question: When a client's nasogastric tube (NG) tube becomes clogged the nurse attempted to aspirate with a large-bore syringe, but with no success. What should the nurse do next? Answer: Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

Explanation: Warm water irrigation is one of the methods that can be used to unclog a feeding tube. Removal is not warranted at this early stage and a flicking motion is unlikely to have an effect. The tube should not be withdrawn, even a few centimeters.

Question: A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? Answer: diaphoresis, vomiting, and diarrhea.

Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

Question: To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? Answer: Avoid coffee and alcoholic beverages

Explanation: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.