The nurse is caring for a patient after a Bilroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which would the nurse clarify?

Early ambulation

Leg exercises

Coughing and deep-breathing exercises

Irrigating the nasogastric (NG) tube

Answer and Explanation

The Correct Answer is D

After a Billroth II (gastrojejunostomy) procedure, the nasogastric (NG) tube should not be irrigated unless specifically ordered by the surgeon. Irrigation could disrupt the surgical anastomosis. Therefore, if the postoperative prescriptions include irrigating the NG tube, the nurse should clarify this with the surgeon

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Correct Answer is D

Explanation

Choice A rationale
Removing the protective gown before exiting the patient’s room is a standard practice in infection control. However, it is not the most critical action when caring for a client with Clostridioides difficile under contact precautions.
Choice B rationale
Utilizing an electronic thermometer to measure the client’s temperature is a routine part of patient care and is not specific to contact precautions for Clostridioides difficile.
Choice C rationale
Shaking bed linens before placing them in a linen bag can potentially spread Clostridioides difficile spores, increasing the risk of transmission.
Choice D rationale
Taking off the protective gown prior to removing gloves is the correct sequence for doffing personal protective equipment (PPE). This sequence is important to prevent the spread of Clostridioides difficile to the healthcare provider and other patients.

A. Place enough formula in the feeding bag to last for 8 hr of continuous feeding. B. Flush the tube with 30 mL of water every 4 hr. C. Change the feeding bag and tubing every 72 hr. D. Keep the head of the bed elevated at 15 degrees.

Correct Answer is B

Explanation

Choice A rationale

While it’s important to ensure the feeding bag contains enough formula for the feeding period, it’s not recommended to fill the bag with more than 4-6 hours’ worth of formula at a time due to the risk of bacterial growth.
Choice B rationale
This is the correct answer. Flushing the gastrostomy tube with water every 4 hours helps maintain tube patency and hydrates the patient.
Choice C rationale
Changing the feeding bag and tubing every 72 hours is a common practice, but it’s not the most critical intervention in this scenario.
Choice D rationale
Keeping the head of the bed elevated at 30 to 45 degrees during feeding and for 1 to 2 hours afterward is recommended to minimize the risk of aspiration. However, 15 degrees may not be sufficient.

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The nurse is caring for a patient after a Bilroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which would the nurse clarify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has recently been diagnosed with Clostridium difficile and is under contact precautions. What action should the nurse take?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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