Chapter 39 course point Med surg 2

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assessing lung sounds

A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine?

Buccal mucosa next to the upper molars

The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state

"Many oral cancers produce no symptoms in the early stages."

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:

Make a notation on the call light system that the client cannot speak.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80 to 120 mL

The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care?

Baking soda and water

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter.

A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is mostappropriate?

Keep the client in semi-Fowler position for 1 hour after feedings

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply.

Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)

Which of the following is the most common type of diverticulum?

Zenker's diverticulum

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?

cranberry juice

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?

diaphoresis, vomiting, and diarrhea.

The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?

nasogastric intubation

The nurse is caring for a group of clients. Which client(s) would be a candidate for total parenteral nutrition (TPN)? Select all that apply.

Man with two-thirds of his colon removed Child with short bowel syndrome Middle-aged man with acute pancreatitis

A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care?

Risk for Aspiration Related to Inhalation of Gastric Contents

The nurse is preparing to administer orlistat to a client with obesity. Which safety warning(s) should the nurse consider when administering this medication to the client? Select all that apply.

Monitor liver function. Administer with meals, stagger administration with other drugs. Provide a vitamin supplement with the medication.

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?

Monitoring the feeding closely.

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?

Parotid

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse?

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client?

Provide the client with an irrigating solution of baking soda and warm water.

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?

Sialadenitis

Which of the following refers to a bacterial or viral infection of the salivary glands?

Sialadenitis

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration?

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?

metoclopramide

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?

30 minutes

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30-mL

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse

Administers an initial bolus of 50 mL water

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?

4

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42

After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement?

"I will be lying on my back but my legs will be higher than my head."

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

1 hour

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?

225 mL

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?

6

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6 hours

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time?

6 p.m. to 8 p.m.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?

A canker sore of the oral soft tissues

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education?

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education?

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?

Assess the graft for color and temperature.

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?

Achalasia

A nurse is performing an assessment for a client who presents to the clinic with an erythemic, fissuring lip lesion with white hyperkeratosis. What does the nurse suspect that these findings are characteristic of?

Actinic cheilitis

The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome?

Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.

A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time?

An effective means of communicating with the nurse

The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings?

Aphthous stomatitis

A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first?

Apply pressure to the bleeding site

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse?

Attaches the fat emulsion tubing to a Y connector close to the infusion site

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lung sounds every 4 hours.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client?

Brush and floss daily.

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?

Dumping syndrome

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

Dysphagia

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.

Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly.

A client has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. What is the nurse's best response to this change in health status?

Ensure that none of the client's visitors have an infection.

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?

Exhibiting hemoglobin A1C 8.2

A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action?

Explain the process clearly to the client.

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply.

Family support• Telephone access• Motivation for learning• Health status

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?

Fluid volume deficit

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

A client with a diagnosis of late-stage Alzheimer disease has begun supplemental feedings through a nasogastric (NG) tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding?

Frequent lung auscultation

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?

Gastroesophageal reflux disease

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

Gastroesophageal reflux disease

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation.

A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document?

Hairy leukoplakia

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

Hang a solution of dextrose 10% and water until the new solution is available.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

High epigastric pain and/or discomfort

A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?

Imbalanced Nutrition: Less Than Body Requirements

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?

Increasing difficulty in swallowing

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is

Inserted into the lungs

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?

Instruct the client to swish prescribed nystatin solution for 1 minute.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.

Intake and output monitoring Calorie counts for oral nutrients Daily weights

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?

Levin tube

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

Lithotripsy

Which of the following are functions of saliva? Select all that apply.

Lubrication Protection against harmful bacteria Digestion

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to?

Maintaining a patent airway

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Metoclopramide (Reglan)

The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate?

Notify the physician

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about?

Nystatin

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?

Palpate the client's parotid glands to detect swelling and tenderness.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Place the client in the Fowler's position.

A nursing educator reviewing the care of clients with feeding and endotracheal tubes (ET) emphasizes the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?

Prevent aspiration

A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is:

Proton pump inhibitors.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care?

Provide frequent mouth care.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.

Tachycardia Diaphoresis Diarrhea

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.)

Until bowel sound is present Until flatus is passed Until peristalsis is resumed

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location?A

Tip of patient's nose

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?

Uncontrolled rhythmic movements of the face or limbs

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method?

X-ray visualization

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of

organic fruit juice.

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift.