Chapter 46: Care of Patients with Oral Cavity and Esophageal conditions

2. The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Assisting with position changes and getting out of bed 2. Keeping the head of the bed elevated to at least 30 degrees 3. Reminding the client to use the spirometer every 4 hours 4. Taking and recording vital signs per hospital protocol 5. Titrating oxygen based on the clients oxygen saturations

1. Assisting with position changes and getting out of bed 2. Keeping the head of the bed elevated to at least 30 degrees 4. Taking and recording vital signs per hospital protocol Rationale: The UAP can assist with mobility, keep the head of the bed elevated, and take and record vital signs. The clien needs to use the spirometer every 1 to 2 hours. The nurse titrates oxygen.

4. The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) 1. I just joined a gym, so I hope that helps me lose weight. 2. I sure hate to give up my coffee, but I guess I have to. 3. I will eat three small meals and three small snacks a day. 4. Sitting upright and not lying down after meals will help. 5. Smoking a pipe is not a problem and I dont have to stop.

1. I just joined a gym, so I hope that helps me lose weight. 2. I sure hate to give up my coffee, but I guess I have to. 3. I will eat three small meals and three small snacks a day. 4. Sitting upright and not lying down after meals will help. Rationale: Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms.

A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective? 1. I can only take this medicine at night. 2. I should take this on a full stomach. 3. This drug decreases stomach acid. 4. This should be taken 1 hour before meals.

2. I should take this on a full stomach. Rationale: Gaviscon should be taken with food in the stomach. It can be taken with meals at any time. Its mechanism of action is not to decrease stomach acid.

8.A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority? A. Assess the clients oxygenation. B. Facilitate a STAT chest x-ray. C. Prepare for immediate surgery. D. Start two large-bore IVs.

A. Assess the clients oxygenation. Rationale: The priorities of care are airway, breathing, and circulation. The priority option is to assess oxygenation. This occurs before diagnostic or therapeutic procedures. The client needs two large-bore IVs as a trauma client, but oxygenation comes first.

3.A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching? a. After the operation I can eat anything I want. b. I will have to eat smaller, more frequent meals. c. I will take stool softeners for several weeks. d. This surgery may not totally control my symptoms.

a. After the operation I can eat anything I want. Rationale: Nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. The other statements show good understanding.

6. A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method. b. Explain that staff will answer the call light promptly. c. Give the client a Magic Slate to write on postoperatively. d. Reassure the client that you will take care of all of his or her needs.

a. Agree on a postoperative communication method. Rationale: Before surgery that interrupts the clients ability to communicate, the nurse, client, and family (if possible) agree upon a method of communication in the postoperative period. The client may or may not prefer a slate and may not be able to communicate in writing. Reassuring the client and telling him or her you will take care of all of his or her needs does not help the client be an active participant in care. Ensuring that the staff will answer the call light promptly will not guarantee this will occur.

2. A client has a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

a. Airway Rationale: Airway alwaystakespriority. Airwaymust beassessedfirst and anyproblems resolvedif present

1. The nurse is caring for a client with sialadenitis. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying warm compresses b. Massaging salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabse. Reminding the client to avoid speaking

a. Applying warm compresses c. Offering fluids every hour Rationale: The UAP can apply warm compresses and offer fluids. Massaging salivary glands can be done, but not by the UAP. Lemon-glycerin swabs are drying and should not be used. Speaking has no effect on this condition.

3.A client has been discharged to an inpatient rehabilitation center after an esophagogastrectomy. What menu selections by the client at the rehabilitation center indicate a good understanding of dietary instructions? (Select all that apply.) a. Boost supplement b. Greek yogurt c. Scrambled eggs d. Whole milk shake e. Whole wheat

a. Boost supplement b. Greek yogurt c. Scrambled eggs d. Whole milk shake Rationale: Malnutrition is a serious problem after this procedure. The client needs high-protein, high-calorie foods that are easy to chew and swallow. The Boost supplement, Greek yogurt, scrambled eggs, and whole milk shake are all good choices. The whole wheat bread, while heart healthy, is not a good choice as it is dry and not easy to chew and swallow.

6.A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

a. Chocolate c. Citrus fruits d. Peppermint e. Tomato sauce Rationale: Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.

2. A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner b. Electrician c. Metal worker d. Plumber e. Textile worker

a. Coal miner c. Metal worker d. Plumber e. Textile worker Rationale: The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk.

1. The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity Rationale: Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infectionsare not implicated in the development of GERD, although infection with Helicobacter pylori is.

5. The nurse reads a clients chart and sees that the health care provider assessed mucosal erythroplasia. What should the nurse understand that this means for the client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor

a. Early sign of oral cancer Rationale: Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

8. A client is prescribed cetuximab (Erbitux) for oral cancer and asks the nurse how it works. What response by the nurse is best? a. It blocks epidermal growth factor. b. It cuts off the tumors blood supply. c. It prevents tumor extension. d. It targets rapidly dividing cells.

a. It blocks epidermal growth factor. Rationale: Cetuximab (Erbitux) targets and blocks the epidermal growth factor, which contributes to the growth of oral cancers. The other explanations are not correct.

6.A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the clients psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements.

b. Assess the clients psychosocial status. Rationale: Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the clients psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope.

7. A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? a. Client having a radial neck dissection tomorrow who is asking questions b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning c. Client who is 1 day postoperative for an oral tumor resection who is reporting pain d. Client waiting for discharge instructions after a small tumor resection

b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning Rationale: The client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last.

4. A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? a. Client who has poor oral hygiene practices b. Client who smokes and drinks daily c. Client who tans for an upcoming vacation d. Client who occasionally uses illicit drugs

b. Client who smokes and drinks daily Rationale: Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers.

5.A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client? a. Enteral tube feeding b. Esophageal dilation c. Nissen fundoplication d. Photodynamic therapy

b. Esophageal dilation Rationale: Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer.

4.A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? a. Choosing foods that are easy to swallow b. Lungs clear after meals and snacks c. Properly performing swallowing exercises d. Weight unchanged after 2 weeks

b. Lungs clear after meals and snacks Rationale: All these assessment findings are positive for this client. However, this client is at high risk for aspiration. Clear lungs after eating indicates no aspiration has occurred. Choosing easy-to-swallow foods, performing swallowing checks, and having an unchanged weight do not assess aspiration, and therefore do not indicate that the priority goal has been met.

1. A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the studen nurse requires the registered nurse to intervene? a. Assisting the client to perform oral care every 2 hours b. Preparing to administer a viscous lidocaine gargle c. Reminding the client not to swallow nystatin (Mycostatin) d. Teaching the client to use a soft-bristled toothbrush

b. Preparing to administer a viscous lidocaine gargle Rationale: Viscous lidocaine gargles or mouthwashes are sometimes prescribed for clients with stomatitis and pain. However, the numbing effect can lead to choking or mouth burns from hot food. This client already has difficulty swallowing, so this medication is not appropriate. Therefore, the nurse should intervene when the student prepares to administer this preparation. The other options are correct actions.

10.A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first? a. Notify the surgeon. b. Put on a pair of gloves. c. Reinsert the NG tube. d. Take a set of vital signs.

b. Put on a pair of gloves. Rationale: To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking vital signs and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back to the operating room.

7.A client is 1 day postoperative after having Zenkers diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate? a. Document the findings as normal. b. Irrigate the NG tube with sterile saline. c. Notify the surgeon about this finding. d. Remove and reinsert the NG tube.

c. Notify the surgeon about this finding. Rationale: NG tubes placed during surgery should not be irrigated or moved unless prescribed by the surgeon. The nurse should notify the surgeon about this finding. Documentation is important, but this finding is not normal.

11.A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

c. Omeprazole (Prilosec) Rationale: Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.

9.A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene? a. Checking tube placement every 4 to 8 hours b. Monitoring and documenting drainage from the NG tube c. Pinning the tube to the gown so the client cannot turn the head d. Providing oral care every 4 to 8 hours

c. Pinning the tube to the gown so the client cannot turn the head Rationale: The client should be able to turn his or her head to prevent pulling the tube out with movement. The other actions are appropriate.

9. A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the clients intake. c. Place the client in a high-Fowlers position. d. Remove the inner cannula for cleaning.

c. Place the client in a high-Fowlers position Rationale: To promote airway clearance, this client should be placed in a semi- or high-Fowlers position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula.

12. After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best? a. Bacteria can often cause ulcers. b. This operation often causes ulcers. c. The medication keeps your blood pH low. d. It prevents stress-related ulcers.

d. It prevents stress-related ulcers. Rationale: After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The other responses are incorrect.

2.A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? a. Document the findings in the chart. b. Notify the surgeon immediately. c. Reassess the drainage in 1 hour. d. Take a full set of vital signs.

d. Take a full set of vital signs. Rationale: The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess.

3. A female client hospitalized for an unrelated problem has a large pearly-white lesion on her lip, to which she continues to apply lipstick that she will not remove for inspection. The client refuses to discuss the lesion with the nurse or health care provider. What action by the nurse is best? a. Ask the client why her appearance is so important. b. Ignore the lesion since the client will not discuss it. c. Inform the client that early-stage cancer is curable. d. Work with the client to establish a trusting relationship.

d. Work with the client to establish a trusting relationship. Rationale: Clients with oral cancers often have body image difficulties due to the location of the tumor or the results of surgical treatment. This client appears to be using denial to cope with this problem. The nurse should work to establish a helping-trusting relationship in hopes that the client will be amenable to future discussions about the lesion. Asking why questions often puts people on the defensive and should be avoided. Ignoring the