Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

Client describes a schedule for antacid use with other prescribed medications.

Client selects a pattern of small meals alternating with fluid intake.

Client expresses a willingness to reduce nicotine intake.

Client agrees to participate in a variety of stress reduction techniques.

Answer and Explanation

The Correct Answer is B

A.   Client describes a schedule for antacid use with other prescribed medications: While antacids might be part of the management plan, they do not address the underlying issue of rapid gastric emptying.
B.   This is the most relevant outcome for a client who has developed post-Billroth II dumping syndrome, characterized by nausea, diarrhea, and diaphoresis after meals. Small, frequent meals with fluid intake between meals can help regulate blood sugar levels and reduce the rapid emptying of stomach contents into the small intestine, which is a primary cause of dumping syndrome.
C.   Smoking can affect overall health but is not directly related to dumping syndrome.
D.   Stress management is important for overall well-being but does not directly address the physiological changes causing dumping syndrome.

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Correct Answer is []

Explanation

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.

A. Compare the weight with what it was at last visit. B. Report serum potassium to healthcare provider. C. Review the dietary history from the past week. D. Check the pretibial areas and ankles for edema.

Correct Answer is B

Explanation

A. While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B. The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C. Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D. Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.

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Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

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Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Correct Answer is B

Explanation

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Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

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