a client with a peptic ulcer had a partial gastrectomy and vagotomy billroth i in planning the discharge teaching the client should be cautioned by th
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ATI LPN

ATI NCLEX PN Predictor Test

1. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?

Correct answer: D

Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.

2. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

Correct answer: A

Rationale: The correct answer is A. Putting the glove on the dominant hand first is a key step in maintaining sterile technique as it reduces the risk of contamination. By covering the dominant hand first, the nurse minimizes the risk of contaminating the other hand during the glove application process. Choices B, C, and D are incorrect. Choice B introduces the concept of a sterile gown, which is not relevant to the question about applying sterile gloves. Choice C is incorrect as putting sterile gloves last does not follow the correct sequence of steps in maintaining sterility. Choice D, while important, is not as critical as covering the dominant hand first when applying sterile gloves.

3. A client with a tracheostomy shows signs of respiratory distress. What action should the nurse take immediately?

Correct answer: C

Rationale: The correct immediate action for a client with a tracheostomy showing signs of respiratory distress is to suction the tracheostomy. Respiratory distress in this case is often caused by a blockage, which can be quickly relieved by suctioning to clear the airway. Increasing the suction setting on the ventilator (Choice A) may not address the immediate blockage in the tracheostomy. Administering a bronchodilator (Choice B) may help with bronchoconstriction but does not address the potential blockage in the tracheostomy. Encouraging deep breathing exercises (Choice D) may not be effective in relieving the immediate respiratory distress caused by a blocked tracheostomy.

4. What are the risk factors for developing pneumonia in older adults?

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

Correct answer: D

Rationale: In a situation where a verbal prescription for restraints is obtained for a client experiencing acute mania, the nurse should document the client's condition every 15 minutes. This frequent documentation allows for accurate monitoring of the client's condition, ensuring safety and compliance. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is not directly related to the need for restraints in this scenario. Obtaining a prescription for restraint within 4 hours (Choice C) is not a priority when a verbal prescription is already obtained and immediate action is needed for the client's safety.

Similar Questions

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A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?
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