chapter 22: Med surg

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? A)4 B)6 C)8 D)10

A) 4 Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.

Which is the primary symptom of achalasia? A) Difficulty swallowing B)Chest pain C)Heartburn D) Pulmonary symptoms

A) Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? A) Instruct the client to swish prescribed nystatin solution for 1 minute. B) Remove the plaque from the mouth by rubbing with gauze. C)Provide saline rinses prior to meals. D) Encourage the client to ingest a soft or bland diet.

A) Instruct the client to swish prescribed nystatin solution for 1 minute. A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is anitfungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.

A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame? A)5 to 10 minutes B) 10 to 15 minutes C)15 to 20 minutes D)20 to 25 minutes

B) 10-15 minutes Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? A)20 to 40 mL B)50 to 75 mL C) 80 to 120 mL D)160 to 200 mL

C) 80-120

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n) A) lichen planus. B) actinic cheilitis. C)chancre. D) leukoplakia.

C) chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus are white papules at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.

Rebound hypoglycemia is a complication of parenteral nutrition caused by A) glucose intolerance. B) fluid infusing rapidly. C) feedings stopped too abruptly. D) a cap missing from the port.

C) feeding stopped to abruptly Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.

Total parenteral nutrition (TPN) has been ordered for a male patient who has been experiencing a severe and protracted exacerbation of Crohn's disease. Before TPN can be initiated, the patient requires: A) A random blood glucose level of ≤160 mg/dL B)Angiography to determine the patency of his vascular system C)The insertion of a central venous access device D) A fluid challenge to assess his renal function

C)The insertion of a central venous access device Because of its high osmotic pressure, TPN may only be administered through a central line. Its use does not directly depend on renal function or specific blood glucose levels. Angiography is not required before the initiation of TPN.

To ensure patency of central venous line ports, diluted heparin flushes are used A)with continuous infusions. B) before drawing blood. C)when the line is discontinued. D)daily when not in use.

D) daily when not in use Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing A)pyrosis. B) dyspepsia. C)dysphagia. D) odynophagia.

A) Pyrosis Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.

The nurse is performing an assessment for a patient who presents to the clinic with a lip lesion. The lesion is erythemic, is fissuring, and has white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? A)Actinic cheilitis B)Human papillomavirus lesion C) Frey syndrome D)Sialadenitis

A)Actinic cheilitis Actinic cheilitis is an irritation of the lips associated with scaling, crusting, fissure; white overgrowth of horny layer of epidermis (hyperkeratosis).

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease: A)there are usually no symptoms. B) symptoms include mouth pain. C) symptoms include oral bleeding. D)symptoms include oral numbness.

A)there are usually no symptoms.

The patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? A)Prime the tubing with 20 mL of normal saline. B) Keep the vent lumen above the patient's stomach level. C) Maintain the patient in a high Fowler's position. D)Have the patient pin the tube to the thigh.

B) Keep the vent lumen above the patient's stomach level. The blue vent lumen should be kept above the patient's stomach to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way antireflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, you do not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

A nurse is providing home care to a client receiving intermittent tube feedings. The client wants to take an over-the-counter allergy medication. The medication would need to be given via feeding tube because the client has difficulty swallowing. The nurse checks the medication and finds that it is a timed-release tablet. Which action by the nurse would be most appropriate? A)Tell the client to dissolve the tablet in water to administer it. B)Have the client mix it with the feeding formula after crushing the tablet. C)Check with the pharmacy for an alternative formulation for the drug. D)State that the client cannot take the drug anymore.

C)Check with the pharmacy for an alternative formulation for the drug. Timed-release medications should not be crushed. Rather, the nurse should check with the pharmacy to see if another formulation (e.g., liquid) is available that can be used safely with a feeding tube. Dissolving the tablet in water, like crushing it, would affect the drug's action, possibly releasing too much of the drug too quickly. Stating that the client cannot take the drug anymore is inappropriate. A change in formulation or possibly a change to another drug in an appropriate formulation would be appropriat

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): A)Extension of the esophagus through an opening in the diaphragm. B) Involution of the esophagus, which causes a severe stricture. C)Protrusion of the upper stomach into the lower portion of the thorax. D)Twisting of the duodenum through an opening in the diaphragm.

C)Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? A)compressed tablets B) buccal or sublingual tablets C)enteric-coated tablets D)soft, gelatin capsules filled with liquid

C)enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for clients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for clients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the client undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.