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 C

Explanation

Choice A reason: Pressuring the patient to proceed disregards her autonomy and right to revoke consent. Exploring her concerns respects her decision, making this incorrect, as it dismisses the patient’s expressed wish to cancel the mitral valve replacement surgery during transport.

Choice B reason: Highlighting rescheduling delays may coerce the patient, undermining her right to refuse. Addressing her fears validates her feelings, making this incorrect, as it prioritizes logistics over the patient’s autonomy and emotional state during the surgical consent process.

Choice C reason: Asking about the patient’s thoughts acknowledges her fear and respects her right to revoke consent, facilitating open communication. This aligns with ethical nursing practice, making it the correct response to support the patient’s decision regarding mitral valve replacement surgery.

Choice D reason: Dismissing the patient’s refusal with reassurance about medications ignores her autonomy and consent rights. Exploring her concerns is more appropriate, making this incorrect, as it fails to address the patient’s explicit wish to cancel the surgery during transport.

A. Client whose deep tendon reflexes have become hyperactive. B. Client who displays plantar flexion when the bottom of the foot is stroked. C. Client who consistently demonstrates decortication when stimulated. D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 10.

Correct Answer is D

Explanation

Choice A reason: Hyperactive reflexes suggest neurological irritability but are less urgent than a GCS drop from 15 to 10, indicating deteriorating consciousness. This is incorrect, as it’s lower priority than the nurse’s focus on a client with a significant neurological decline.

Choice B reason: Plantar flexion (Babinski sign) may indicate neurological issues, but a GCS drop to 10 signals acute deterioration, requiring immediate attention. This is incorrect, as it’s less critical than the nurse’s priority to assess the client with a declining GCS.

Choice C reason: Decortication indicates severe brain injury but, if consistent, is less acute than a GCS drop from 15 to 10, suggesting rapid worsening. This is incorrect, as it’s not the nurse’s first priority compared to the client with acute neurological change.

Choice D reason: A GCS drop from 15 to 10 indicates a significant decline in consciousness, a neurological emergency requiring immediate assessment. This aligns with neurosurgical priorities, making it the correct client for the nurse to prioritize on the unit.

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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

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

Correct Answer is C

Explanation

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Correct Answer is D

Explanation

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