The nurse is caring for a patient after a Bilroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which would the nurse clarify?
Early ambulation
Leg exercises
Coughing and deep-breathing exercises
Irrigating the nasogastric (NG) tube
The Correct Answer is D
After a Billroth II (gastrojejunostomy) procedure, the nasogastric (NG) tube should not be irrigated unless specifically ordered by the surgeon. Irrigation could disrupt the surgical anastomosis. Therefore, if the postoperative prescriptions include irrigating the NG tube, the nurse should clarify this with the surgeon
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Asking the patient to share their concerns allows the nurse to understand the patient’s perspective and provide individualized care. It opens up a dialogue where the patient can express their fears and the nurse can provide reassurance and information.
Choice B rationale
While it’s true that many people worry about managing an ileostomy at first, this response does not address the patient’s specific concerns. It’s important to understand the patient’s individual fears and worries.
Choice C rationale
This response may be misleading. While an ileostomy can help manage the symptoms of ulcerative colitis, it does not cure the disease. It’s important to provide accurate information to the patient.
Choice D rationale
Discussing strategies to adapt to life with an ileostomy can be helpful, but it’s important to first understand the patient’s specific concerns. This response assumes what the patient needs without asking them.
Correct Answer is C
Explanation
Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice B rationale
Hyperactive bowel sounds are not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice C rationale
Severe upper abdominal pain is a common sign of gastrointestinal perforation in peptic ulcer disease25. The pain is often sudden and severe, and it may spread to the back or shoulder.
Choice D rationale
A report of epigastric fullness is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
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