A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

Leg exercises.

Early ambulation.

Irrigating the nasogastric tube.

Coughing and deep-breathing exercises.

Answer and Explanation

The Correct Answer is C

Choice A reason: Leg exercises prevent thrombosis post-gastrojejunostomy, a standard order. Irrigating the NG tube risks anastomosis disruption, making this incorrect, as it’s a safe prescription the nurse wouldn’t question in the client’s postoperative care plan.

Choice B reason: Early ambulation reduces complications like pneumonia after Billroth II surgery. Irrigating the NG tube is risky, making this incorrect, as it’s a standard order the nurse wouldn’t need to verify in the postoperative period.

Choice C reason: Irrigating the nasogastric tube post-gastrojejunostomy risks disrupting the surgical anastomosis, causing leakage. This requires verification, aligning with surgical safety, making it the correct prescription the nurse would question in the client’s postoperative care.

Choice D reason: Coughing and deep-breathing exercises prevent atelectasis post-surgery, a routine order. Irrigating the NG tube is concerning, making this incorrect, as it’s a safe prescription the nurse wouldn’t question in the client’s recovery plan.

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Correct Answer is D

Explanation

Choice A reason: Monitoring is important but doesn’t address the urgency of headache, nausea, and restlessness, suggesting disequilibrium syndrome. Notifying the provider is critical, making this incorrect, as it delays the nurse’s priority action to manage a serious post-dialysis complication.

Choice B reason: Elevating the head of the bed may help comfort but doesn’t treat potential disequilibrium syndrome indicated by headache and restlessness. Notifying the provider is urgent, making this incorrect, as it’s less critical than the nurse’s need to report symptoms.

Choice C reason: Assessing the fistula site is routine but unrelated to headache and nausea, which suggest a neurological issue. Notifying the provider takes precedence, making this incorrect, as it’s not the priority compared to addressing potential post-dialysis complications.

Choice D reason: Notifying the provider is the priority for headache, nausea, and restlessness post-hemodialysis, as these suggest disequilibrium syndrome, a serious complication. This aligns with dialysis care protocols, making it the correct action for the nurse to take immediately.

A. Pedal pulse 88 beats/min, bilaterally. B. No swelling noted in lower extremities. C. Spontaneous respirations, 16 breaths/minute. D. Pulse oximeter reading 93%. E. Pain scored 5 out of 10, decreased from high of 10. F. Temperature 98.6°F.

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Bilateral pedal pulses at 88 beats/min indicate restored circulation post-fasciotomy, preventing compartment syndrome. This aligns with vascular assessment post-burn and fracture, making it a correct finding showing the nurse’s actions were effective in maintaining perfusion in the leg.

Choice B reason: No swelling in lower extremities post-fasciotomy indicates reduced pressure and effective decompression, preventing tissue damage. This aligns with post-surgical burn care, making it a correct finding demonstrating the nurse’s actions were successful in managing the client’s leg injury.

Choice C reason: Spontaneous respirations are expected with intubation but unrelated to fasciotomy effectiveness for leg burn and fracture. Pulse presence is more relevant, making this incorrect, as it does not reflect the outcome of the nurse’s actions on the leg injury.

Choice D reason: Pulse oximetry of 93% reflects respiratory status, not fasciotomy effectiveness for leg perfusion. No swelling is a direct outcome, making this incorrect, as it’s unrelated to the nurse’s actions addressing the burn and fracture in the client’s leg.

Choice E reason: Pain reduced to 5/10 from 10 post-fasciotomy indicates effective decompression and pain management. This aligns with post-surgical burn care outcomes, making it a correct finding showing the nurse’s actions improved the client’s comfort and leg injury status.

Choice F reason: Normal temperature of 98.6°F is expected but doesn’t directly indicate fasciotomy effectiveness for leg perfusion. Pedal pulses are more specific, making this incorrect, as it’s not a primary outcome of the nurse’s actions for the client’s leg injury.

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A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Correct Answer is D

Explanation

Correct Answer is ["A","B","E"]

Explanation

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