(PrepU) Chapter 39: Management of Patients with Oral and Esophageal Disorders

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance? INTAKE: Tube feeding 480 mL Water 120 mL IVPB 50 mLLiquid medications 60 mL OUTPUT: Urine 450 mL

260 Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

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. Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.

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

Catheter hub The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule 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.

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 Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?

Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

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 Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.

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 Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

Ineffective airway clearance related to obstruction by mucus All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.

A client receiving tube feedings has prescriptions for several drugs. Which drugs would the nurse expect to administer to the client without any special preparation? Select all that apply.

Liquid stool softener Sublingual nitroglycerin Liquid medications do not require any special preparation for administration via a feeding tube. Buccal or sublingual tablets are administered as prescribed. They are absorbed through the mucosa of the cheek or under the tongue and thus would not be administered through the feeding tube. Enteric-coated aspirin and sustained-release antihypertensive could not be given as is through a feeding tube. A change in formulation would be needed. An acetaminophen tablet would need to be crushed and dissolved in water before being given.

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

Lithotripsy 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.

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).

An older client is diagnosed with parotitis. What bacterial infection does the nurse suspect caused the client's parotitis?

Staphylococcus aureus The elderly and debilitated clients experience decreased salivary flow from general dehydration or medications. The bacterial infection is usually caused by Staphylococcus aureus. The infecting organism travels from the mouth through the salivary gland. Pseudomonas, pneumococcus, and streptococcus are less likely to specifically affect the elderly or debilitated clients.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

To ensure patency of central venous line ports, diluted heparin flushes are used

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.

The nurse provides health teaching to inform the client with oral cancer that

many oral cancers produce no symptoms in the early stages. The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.

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 instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

The most significant complication related to continuous tube feedings is

the increased potential for aspiration. Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

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 cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal 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 client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal. If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the health care provider. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the health care provider who will make a determination of leaving out or inserting a new nasogastric tube.

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 nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.