Honan-Chapter 22: Nursing Management: Patients With Oral and Esophageal Disorders and Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: A. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. B. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. C. Feedings can be administered with the patient in the recumbent position. D. The patient cannot experience the deprivational stress of not swallowing.

A. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. RATIONALE Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

The nurse recognizes which of the following as a cause of xerostomia? Select all that apply. A. HIV infection B. Oral hypoglycemic medications C. Tracheostomy tube D. Inability to close the mouth E. Kidney failure

A. HIV infection C. Tracheostomy tube D. Inability to close the mouth RATIONALE Xerostomia is the decreased production or cessation of saliva production in the mouth. It is seen in patients receiving psychopharmacologic agents, patients with HIV, patients who cannot close the mouth, patients having endotracheal tubes or tracheostomy tubes, and patients with poor oral food intake. Oral hypoglycemic medications and kidney failure are not associated with xerostomia.

A nurse is caring for a patient who is on strict bowel rest and will need IV nutrition. The nurse knows the following devices are appropriate for TPN. Select all that apply. A. PICC line B. Triple-lumen catheter C. Large-bore IV line D. Implantable venous assess device (Port-A-Cath) E. Arterial line

A. PICC line B. Triple-lumen catheter D. Implantable venous assess device (Port-A-Cath) RATIONALE An IV line is inserted into a peripheral vein, and an IID is an intermittent infusion devise, both are IVs in peripheral veins. Peripheral veins cannot be used for TPN which has a high solute level and therefore is too concentrated for a peripheral vein; additionally the high dextrose solution can damage the intima of smaller vessels. PICC lines are placed in the arm and terminate in a central vein. A triple-lumen catheter is commonly inserted in one of two central veins, the internal jugular or subclavian vein; Port-A-caths are often surgically implanted in the subclavian vein. An arterial line, commonly used to monitor blood pressure and for blood sampling cannot be used for TPN or infusion of TPN or any other medication.

An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2° F. 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? A. Palpate the patient's parotid glands to detect swelling and tenderness. B. Assess the temporomandibular joint for evidence of a malocclusion. C. Test the integrity of the 12th cranial nerve by asking the patient to protrude his tongue. D. Inspect the patient's gums for bleeding and hyperpigmentation.

A. Palpate the patient's parotid glands to detect swelling and tenderness. RATIONALE Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness and swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention? A. Place the client in a supine position. B. Elevate the head of the bed 90 degrees during meals. C. Encourage the client to remove dentures. D. Encourage thin liquids for dietary intake.

B. Elevate the head of the bed 90 degrees during meals. RATIONALE The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? A. Radiation B. Lithotripsy C. Chemotherapy D. Biopsy

B. Lithotripsy RATIONALE Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge? A. Hold his breath B. Take long, slow breaths C. Bear down as if having a bowel movement D. Pant like a dog

B. Take long, slow breaths RATIONALE During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the following intervention: A. Change the transparent dressing every 3 days. B. Wear a face mask during dressing changes. C .Assess the PICC insertion site daily. D. Use clean gloves when providing site care.

B. Wear a face mask during dressing changes. RATIONALE The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.

A confused patient prematurely removes her NG tube. The nurse knows to observe for which complication? A. Constipation B. Flatulence C. Abdominal distention D. Gastric bleeding

C. Abdominal distention RATIONALE If the tube is not replaced after its removal, the nurse should watch for abdominal distention, nausea, and vomiting. Constipation is not a complication associated with NG tube removal. Flatulence indicates air is passing through the GI tract. Gastric bleeding is not associated with removal of an NG tube, as the tubes are often soft and flexible.

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? A. Spray the oropharynx with an anesthetic spray. B. Have the patient maintain a backward tilt head position. C. Allow the patient to sip water as the tube is being inserted. D. Have the patient eat a cracker as the tube is being inserted.

C. Allow the patient to sip water as the tube is being inserted. RATIONALE During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.

A nurse receives report on a patient experiencing dumping syndrome. The nurse knows that the patient would be displaying which symptom 30 minutes after eating? A. Difficulty swallowing B. Heartburn C. Nausea D. Cramping in the abdomen

C. Nausea D. Cramping in the abdomen RATIONALE Patients with dumping syndrome are diaphoretic, dizzy, and weak. They also complain of nausea, vomiting, belching and epigastric fullness as well as diarrhea and abdominal cramping. The symptoms are caused by fluid shift in the intestine due to the high tonicity of the feedings. Difficulty swallowing is a common symptom of esophageal diverticulum. Heartburn is associated with GERD.

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? A. Urge the client to regularly rinse the mouth with tap water. B. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. C. Provide the client with an irrigating solution of baking soda and warm water. D. Regularly wipe the outside of the client's mouth to prevent germs from entering.

C. Provide the client with an irrigating solution of baking soda and warm water. RATIONALE If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.

Select the assessment finding that the nurse should immediately report, post radical neck dissection. A. Temperature of 99°F B. Pain C. Stridor D. Localized wound tenderness

C. Stridor RATIONALE Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.

The most common symptom of esophageal disease is A. nausea. B. vomiting. C. dysphagia. D. odynophagia.

C. dysphagia. RATIONALE Dysphagia may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.

The nurse is administering liquids to a patient who has recently been changed from NPO to a clear liquid diet. The patient coughs and occasionally gags with sips of water. Which health care team member would the nurse consult? A. Physical therapist B. Respiratory therapist C. Dietician D. Speech pathologist

D. Speech pathologist RATIONALE After the nurse stops giving the patient oral liquids, they would consult the speech pathologist for a swallowing evaluation. Physical therapists assist patients in regaining motor strength and mobility. Respiratory therapists assess and manage respiratory function and associated treatments. Dieticians evaluate the caloric needs of the patients with various illnesses and determine the correct diet to promote recovery.