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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing breaths follows compressions in ACLS after defibrillation for pulseless ventricular tachycardia. Resuming compressions is immediate, making this incorrect, as it delays the nurse’s priority to restore circulation post-shock in the client’s code situation.
Choice B reason: Assessing the pulse occurs after 2 minutes of compressions, not immediately post-defibrillation. Resuming compressions is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on continuing CPR in pulseless ventricular tachycardia.
Choice C reason: Resuming chest compressions immediately after defibrillation maintains circulation in pulseless ventricular tachycardia per ACLS guidelines. This aligns with code management, making it the correct next step for the nurse to perform to optimize the client’s resuscitation efforts.
Choice D reason: Epinephrine is given after the second shock or per protocol, not immediately post-defibrillation. Compressions are the priority, making this incorrect, as it’s not the next step in the nurse’s ACLS sequence for managing the client’s arrhythmia.
Correct Answer is C
Explanation
Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.
Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.
Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.
Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.
Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.
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