Nursing Elites

1. 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: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

2. Which of the following treatments is used for rectal cancer but not for colon cancer?

• A. Chemotherapy
• B. Colonoscopy
• C. Radiation
• D. Surgical resection

Correct answer: C

Rationale: Radiation therapy is commonly used for rectal cancer to shrink the tumor before surgery, which is not typically done for colon cancer.

3. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?

• A. Hiccups and diarrhea
• B. Fatigue and abdominal pain
• C. Constipation and fever
• D. Diaphoresis and diarrhea

Correct answer: D

Rationale: The correct answer is D: Diaphoresis and diarrhea. Dumping syndrome occurs after gastric surgery when food moves quickly from the stomach to the intestine, causing fluid shifts and leading to symptoms like weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain, distension, hyperactive bowel sounds, and diarrhea. Choices A, B, and C do not reflect the typical signs and symptoms of dumping syndrome.

4. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

• A. Dehydration
• B. Malnutrition
• C. Bleeding
• D. Infection

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

5. Which of the following associated disorders may the client with Crohn’s disease exhibit?

• A. Ankylosing spondylitis
• B. Colon cancer
• C. Malabsorption
• D. Lactase deficiency

Correct answer: A

Rationale: Clients with Crohn's disease may exhibit associated disorders such as ankylosing spondylitis, which is an inflammatory condition affecting the spine.

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