Nokea
The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?
- A. Irrigating the nasogastric tube
- B. Coughing a deep breathing exercises
- C. Leg exercises
- D. Early ambulation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client complains of a sore throat
- B. The client has a temperature of 100*F
- C. The client appears drowsy following the procedure
- D. The client complains of epigastric pain
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
- A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
- B. After insertion into the nostril, instruct the client to extend his neck
- C. Introduce the tube with the client's head tilted back, then instruct him to keep his head upright for final insertion
- D. Instruct the client to hold his chin down, then back for insertion of the tube
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?
- A. Obesity
- B. Volvulus
- C. Constipation
- D. Intestinal obstruction
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?
- A. Nail beds
- B. Skin on the back of the hand
- C. Hard palate of the mouth
- D. Soles of the feet
Correct Answer: C
Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.
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.