Fowler’s position (head of bed (HOB) elevated 45 degrees) increases comfort, ventilation, circulation, and relieves pressure from the thorax. It would be best for this patient due to the pain experienced by the patient in the abdomen. Sims’ position (halfway between lateral and prone, upper arm flex, lower arm behind patient) is used when a patient is receiving an enema or an examination in the perineal area. Trendelenburg (HOB lowered, feet elevated) is used for patients with hypotension, as it promotes venous return. Reverse Trendelenburg (HOB elevated, feet lowered) is used to promote gastrointestinal problems by minimizing esophageal reflux. Side-lying (patient on side with top leg in front of bottom leg and hip/knee flexed) is used to relieve pressure from the sacrum and is often rotated with patients who are on bedrest.

To prevent pain during a bowel movement post operatively, pain medication is often indicated to help make it more tolerable. Pain medications will need to be given post op and may contribute to constipation, but oral stool softeners and and a high fiber diet can help to avoid the constipation. Rectal suppositories and daily enemas are not needed. Bowel movements should not be delayed nor avoided in the post operative period. 

This client is to be on contact precautions, the wearing of a mask is consistent with airborne precautions which is not necessary for C-diff. All other choices are appropriate for contact precautions. 

Acetaminophen causes more liver failure in the United States than viral hepatitis, making it one of the most common causes of liver-related emergency room visits. It causes approximately 78,000 emergency room visits and 150 deaths due to liver failure each year. None of the other medications listed are associated with liver failure.

The majority of liver infections are viral in nature. Hepatitis A, hepatitis B, and hepatitis C are the most frequent agents of infection, with hepatitis C being the leading cause of liver transplants. Bacterial infections in the liver most commonly take the form of an abscess. Fungal hepatitis and prion infection of the liver are not generally seen.

There are multiple viruses that can cause hepatitis other than hepatitis A, B, or C. Among these are Epstein-Barr virus, cytomegalovirus, and yellow fever. 

The correct answer in this question is "Insert two large-bore peripheral IV's."

This is the correct answer because this patient is suffering from a suspected gastrointestinal bleed and based upon the report of the vital signs, he is hemodynamically unstable. In evaluating an emergency/trauma patient, the "ABC's" must be assessed (A= airway, B= breathing, C= circulation). In this patient's case, it is stated that he is responsive and breathing without any issues, indicating that his airway and breathing are both satisfactory. The next issue is his circulation. Given that he has a suspected bleed, and is tachycardic and hypotensive, it is likely that he is losing a significant amount of blood from his bleeding viscera. As such, he may need emergent, rapid fluid and/or blood product resuscitation. The best way to prepare for this immediately is to place two large bore peripheral IV lines, such that resuscitation can be provided through these lines while the rest of the workup and treatment continues. Any delay in placing these lines delays the fluid/blood resuscitation of the patient, which can be dangerous.

At this point, given that the patient has a protected airway and is breathing without issue, intubation would not be indicated. Should his airway or breathing status change, the need can be reassessed.

Administering hydromorphone, a potent opioid, may be necessary if the patient is in a significant amount of pain, but that would not be the most pressing initial concern given that he is hemodynamically unstable.

Administering warfarin, an anticoagulant, would be highly contraindicated in this patient, as he likely has an active gastrointestinal bleed and is hemodynamically unstable.

Administering lorazepam, a benzodiazepine, is not indicated in this hemodynamically unstable patient with a suspected gastrointestinal bleed. After stabilization and continued demonstration of airway protection, if the patient is anxious, this need can be reassessed. 

The correct recommendation is "Eat your last meal at least 3 hours prior to going to bed, and sleep as upright as possible, with multiple pillows." This is correct because this recommendation involves fairly simple lifestyle changes that have the potential to greatly decrease the patient's symptom burden. Heartburn symptoms can be exacerbated in patients who eat spicy foods (at any time), who drink coffee, and/or who eat meals shortly prior to going to bed (since the food can physically reflux back to the distal esophagus from the stomach prior to being digested more completely). Thus, any of those recommendations would be inappropriate. Further, in a patient who is acutely experiencing acid reflux symptoms, it is typically appropriate for them to take calcium carbonate to neutralize the acid and relieve symptoms. As such, advising the patient to not eat immediately prior to going to bed, and to remain upright (to physically minimize reflux of contents) would be the most appropriate recommendation. 

The correct answer is "ondansetron." This is the correct answer because this patient, who is actively being treated with chemotherapy and experiencing severe nausea, is most likely suffering from chemotherapy-induced nausea. The most appropriate first-line treatment for chemotherapy-induced nausea in a patient with a normal QTc interval is ondansetron (also known as Zofran). Ondansetron is a serotonin 5HT-3 receptor antagonist, likely accounting for its anti-nausea properties. A side effect is QTc interval prolongation, and as such, careful consideration as to whether or not to prescribe ondansetron should be given for patients with baseline prolonged QTc intervals. 

Acetaminophen, an analgesic, would not treat nausea, nor would ibuprofen, meloxicam, or ketorolac (all NSAID medications).

The correct answer is "Take 1-2 tablets of calcium carbonate every 3-6 hours as needed for heartburn symptoms, and if you experience symptoms more frequently or severely, return to clinic." This answer is correct because in this patient's case, he is an apparently healthy 40-year old male whose only complaint is very infrequent heartburn that occurs in response to specific trigger foods and drinks (spicy foods and alcoholic beverages). In a patient who experiences mild to moderate heartburn, or acid reflux, symptoms infrequently, meaning less than 3 times per week, the appropriate initial recommendation is to take over-the-counter calcium carbonate tablets as needed, as these will directly neutralize the excess acid in the distal esophagus and stomach. For the majority of patients with infrequent heartburn brought on by known trigger foods and beverages, this will be sufficient to provide symptomatic relief. 

It is inappropriate in a patient with infrequent heartburn who has not yet tried (and failed) calcium carbonate to initiate ranitidine or omeprazole treatment, as these are more potent methods to suppress intrinsic stomach acid production, and are not necessarily required to provide symptomatic relief for these patients. If the patient in this example was experiencing more frequent heartburn, more severe heartburn, or heartburn that was not adequately controlled by calcium carbonate, then ranitidine or omeprazole would be reasonable options. 

The best initial treatment option for a patient with heartburn is not acetaminophen, an over-the-counter analgesic. Heartburn is caused by reflux of acidic gastric contents into the distal esophagus. The best initial treatment for an acute episode of heartburn is calcium carbonate, as this will directly neutralize the acid that is causing symptoms, and provide symptomatic relief for most patients. 

It would be inappropriate to send this patient immediately to the emergency room as he is not currently experiencing heartburn symptoms, his symptoms are highly consistent with heartburn (as opposed to a cardiac etiology), given that they are brought on only infrequently and directly in response to trigger foods and beverages. If the patient was actively complaining of chest pain, and more concerning aspects of his pain were elicited that suggested a cardiac etiology, then an immediate referral to an emergency department would be a more valid consideration.