Priority nursing actions to achieve critical goals in the postoperative period for a client who has just returned from a Billroth II procedure should include
a. encouraging oral intake.
b. ensuring frequent coughing and deep breathing.
c. irrigating the client's NG tube every hour.
d. maintaining the client in the semi-Fowler position.
B
Nurses should thoroughly demonstrate and discuss the importance of deep-breathing exercises or use of an incentive spirometer for any surgical client. Clients should be warned that the high ab-dominal incision with a Billroth II procedure makes deep breathing very uncomfortable and therefore increases the risk of respiratory complications. This client will be NPO for now and will not be allowed oral intake. Irrigation of a surgically-placed NG tube hourly is not a standard order. In the immediate postoperative period, the client will likely be supine or in a low-Fowler position.
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