Nokea
The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?
- A. The stomach pouch becomes overfilled.
- B. The lower half of the stomach becomes spastic.
- C. The duodenum incision becomes inflamed.
- D. The dumping syndrome from a high-protein meal.
Correct Answer: A
Rationale: A. A small pouch (15—20 mL capacity) is constructed in the upper part of the stomach during vertical banded gastroplasty. Overfilling of this pouch stimulates afferent nerve fibers, which relay information to the chemoreceptor trigger zone in the brain, causing nausea. B. The function of the lower half of the stomach is not affected with a vertical banded gastroplasty. C. The duodenum is not incised during a vertical banded gastroplasty. D. Dumping syndrome is more likely to occur from a meal high in simple carbohydrates, not protein.
You may also like to solve these questions
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
Which assessment data supports the client's diagnosis of gastric ulcer to the nurse?
- A. Presence of blood in the client's stool for the past month.
- B. Reports of a burning sensation moving like a wave.
- C. Sharp pain in the upper abdomen after eating a heavy meal.
- D. Complaints of epigastric pain 30 to 60 minutes after ingesting food.
Correct Answer: D
Rationale: Gastric ulcers typically cause epigastric pain 30–60 minutes after eating due to acid irritation of the ulcerated mucosa. Blood in stool is more indicative of lower GI issues, a wave-like sensation is vague, and sharp pain after heavy meals is less specific.
The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?
- A. Steady, aching pain in one specific area.
- B. Sharp back pain radiating to the flank.
- C. Sharp pain increases with deep breaths.
- D. Intermittent colicky pain near the umbilicus.
Correct Answer: D
Rationale: Intermittent colicky pain near the umbilicus is characteristic of bowel obstruction due to peristalsis against the blockage. Steady pain, back pain, and pain with breathing suggest other conditions.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.