Nokea
A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the nurse is reinforcing information about the procedure. Which of the following explanations is most accurate?
- A. The procedure will result in enlargement of the pyloric sphincter
- B. The procedure will result in anastomosis of the gastric stump to the jejunum
- C. The procedure will result in removal of the duodenum
- D. The procedure will result in repositioning of the vagus nerve
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?
- A. Spider angiomas
- B. Fatigue
- C. Pale urine
- D. Weight gain
Correct Answer: B
Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.
Which of the following conditions can cause a hiatal hernia?
- A. Increased intrathoracic pressure
- B. Weakness of the esophageal muscle
- C. Increased esophageal muscle pressure
- D. Weakness of the diaphragmic muscle
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
- A. Notify the physician
- B. Document the findings
- C. Irrigate the T-tube
- D. Clamp the T-tube
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?
- A. Dyspnea and fatigue
- B. Ascites and orthopnea
- C. Purpura and petechiae
- D. Gynecomastia and testicular atrophy
Correct Answer: C
Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?
- A. Monitoring gastric pH to detect complications
- B. Assessing for bowel sounds
- C. Providing nutritional support
- D. Monitoring for symptoms of hemorrhage
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.