the nurse is caring for a client following a billroth ii procedure on review of the postoperative orders which of the following if prescribed should t
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?

Correct answer: A

Rationale: In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.

2. When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?

Correct answer: A

Rationale: Limiting fat intake is a recommended measure to reduce the risk of colon cancer. Including fiber, undergoing annual rectal examinations, and sigmoidoscopy are also important, but limiting fat intake is directly related to reducing cancer risk.

3. Which of the following types of diets is implicated in the development of diverticulosis?

Correct answer: A

Rationale: A low-fiber diet is implicated in the development of diverticulosis because it leads to harder stools and increased pressure in the colon. The lack of fiber results in decreased bulk and slower transit time, predisposing individuals to constipation and the formation of diverticula. High-fiber diets, on the other hand, promote regular bowel movements and help prevent diverticular disease. High-protein and low-carbohydrate diets do not have a direct association with diverticulosis.

4. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

5. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

Correct answer: A

Rationale: Administering a lactulose enema as ordered helps reduce ammonia levels in patients with hepatic encephalopathy.

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