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 B
Explanation
Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.
Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.
Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.
Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.
Correct Answer is D
Explanation
Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.
Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.
Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.
Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.
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