Nokea
A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
- A. Decreases food absorption in the stomach
- B. Heals the gastric mucosa
- C. Halts stress reactions
- D. Reduces the stimulus to acid secretions
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to assist in preventing dumping syndrome?
- A. Eat high-carbohydrate foods
- B. Limit the fluids taken with meals
- C. Ambulate following a meal
- D. Sit in a high-Fowlers position during meals
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following measures should the nurse focus on for the client with esophageal varices?
- A. Recognizing hemorrhage
- B. Controlling blood pressure
- C. Encouraging nutritional intake
- D. Teaching the client about varices
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?
- A. A tube with a single lumen that connects to suction
- B. A tube with a large lumen and an air vent
- C. A Sengstaken-Blakemore tube
- D. A Dobbhoff weighted tube
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?
- A. Inspect skin around the T tube daily for irritation.
- B. Irrigate the T tube every 4 hours to maintain patency.
- C. Maintain the client in a supine position while the T tube is in place.
- D. Keep the T tube clamped except during mealtimes.
Correct Answer: A
Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.