Page 1537 - Saunders Comprehensive Review For NCLEX-RN

539. Answer: 3

Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody
and then turns a greenish-brown color. The drainage is measured as output. The
amount of expected drainage will range from 500 to 1000 mL/day. The nurse would
document the output.
Test-Taking Strategy: Note the strategic words, most appropriate. Options 1 and 2
can be eliminated because a T-tube is not irrigated and would not be clamped with
this amount of drainage. From the remaining options, you must know normal
expected findings following this surgical procedure.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: GI Accessory Organs
Priority Concepts: Clinical Judgment; Elimination
Reference: Lewis et al. (2017), pp. 344, 1009.

540. Answer: 4

Rationale: Perforation of an ulcer is a surgical emergency and is characterized by
sudden, sharp, intolerable severe pain beginning in the midepigastric area and
spreading over the abdomen, which becomes rigid and boardlike. Nausea and
vomiting may occur. Tachycardia may occur as hypovolemic shock develops.
Numbness in the legs is not an associated finding.
Test-Taking Strategy: Focus on the subject, perforation. Option 2 can be
eliminated easily because it is not related to perforation. Eliminate option 1 next
because tachycardia rather than bradycardia would develop if perforation occurs.
From the remaining options, note the strategic words, most likely, to help direct you
to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Upper GI Disorders
Priority Concepts: Clinical Judgment; Safety
Reference: Lewis et al. (2017), p. 912-913.

541. Answer: 3

Rationale: In a gastrojejunostomy (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
prescribed by the primary health care provider. In this situation, the nurse should
clarify the prescription. Options 1, 2, and 4 are appropriate postoperative
interventions.

1537