Nokea
After Billroth II surgery (gastrojejunostomy), the client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high-carbohydrate meal. The nurse should interpret that these symptoms indicate the development of which problem?
- A. Steatorrhea
- B. Duodenal reflux
- C. Hypervolemic fluid overload
- D. Postprandial hypoglycemia
Correct Answer: D
Rationale: A. Although steatorrhea may occur after gastric resection, the symptoms of steatorrhea include fatty stools with a foul odor, not these symptoms. B. The symptoms of duodenal reflux are abdominal pain and vomiting, not these symptoms. Duodenal reflux is not associated with food intake. C. Symptoms of fluid overload would include increased BP, edema, and weight gain, not these symptoms. D. When eating large amounts of carbohydrates at a meal, the rapid glucose absorption from the chime results in hyperglycemia. This elevated glucose stimulates insulin production, which then causes an abrupt lowering of the blood glucose level. Hypoglycemic symptoms of weakness, diaphoresis, anxiety, and palpitations occur.
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The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish rapport with the client to decrease embarrassment of assessing site.
- B. Encourage the client to lie in the lithotomy position twice a day.
- C. Milk the tube inserted during surgery to allow the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood.
Correct Answer: A
Rationale: Establishing rapport reduces embarrassment during perianal assessments, promoting comfort post-hemorrhoidectomy. Lithotomy position is not standard for recovery.
The nurse is assigned to care for four clients. The nurse should plan to assess which client first?
- A. The client with ascites who is having mild dyspnea with activity
- B. The client with a peptic ulcer who now has severe vomiting
- C. The client who had a colonoscopy and is having diarrheal stools
- D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes
Correct Answer: D
Rationale: D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes should be attended to first. Generalized rash indicates an allergic reaction. This could develop into an anaphylactic reaction. B. The client with a peptic ulcer who now has severe vomiting should be attended to second. Vomiting in PUD may indicate a complication such as mechanical obstruction from scarring. C. The client who had a colonoscopy and is having diarrheal stools should be attended to third. Diarrhea may have been the indication for the client’s colonoscopy or a side effect of the bowel prep. A. The client with ascites who is having mild dyspnea with activity can be attended to last. The dyspnea is usually due to the enlarged abdomen.
The nurse is assessing the client recovering from abdominal surgery who has a patient-controlled analgesia (PCA) pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement?
- A. Insist the client take deep breaths.
- B. Notify the surgeon to request a chest x-ray.
- C. Determine the last time the client used the PCA pump.
- D. Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: C
Rationale: Determining PCA use assesses if overmedication is causing shallow respirations, guiding further action. Insisting on breathing, x-rays, or oxygen are secondary without cause.
The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy?
- A. Gastrointestinal bleeding.
- B. Hypoalbuminemia.
- C. Splenomegaly.
- D. Hyperaldosteronism.
Correct Answer: A
Rationale: GI bleeding increases ammonia levels (from blood protein breakdown), a key trigger for hepatic encephalopathy. Other complications are less directly linked to this risk.
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.