Nokea
You're caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?
- A. Flushed, dry skin.
- B. Headache and bradycardia.
- C. Dizziness and sweating.
- D. Dyspnea and chest pain.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure?
- A. Hypoalbuminemia
- B. Increased capillary permeability
- C. Abnormal peripheral vasodilation
- D. Excess rennin release from the kidneys
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct Answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?
- A. Blanched stoma
- B. Edematous stoma
- C. Reddish-pink stoma
- D. Brownish-black stoma
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?
- A. Restrict intake of high-carbohydrate foods.
- B. Increase fluid intake with meals.
- C. Increase fat intake.
- D. Eat three regular meals a day.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?
- A. Stomatitis
- B. Oral candidiasis
- C. Parotitis
- D. Gingivitis
Correct Answer: C
Rationale: The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.