Ch. 45, 46, 47 & 48

A patient is brought to the emergency department by a family member, who states that the patient "drank drain cleaner." What intervention does the nurse anticipate providing to treat this patient? (Select all that apply.)

-Aspirating secretions from the pharynx if respirations are affected -Neutralizing the chemical -Washing the esophagus with large volumes of water

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

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

A client weighs 215 lbs and is 5' 8" tall. The nurse would calculate this client's body mass index (BMI) as which of the following?

32.7

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 with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted.

Which term refers to intestinal rumbling?

Borborygmus

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

pneumothorax

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the

potential risk for aspiration.

Which client requires immediate nursing intervention? The client who:

presents with a rigid, boardlike abdomen.

A client has noticed increased incidence of constipation since a broken ankle caused the client to discontinue taking a daily 3-mile walk. During client education, what does the nurse explain as the mechanical cause of this constipation?

stool remaining in the large intestine too long

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

stridor

The most significant complication related to continuous tube feedings is

the potential for aspiration.

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:

there are usually no symptoms.

A client who had oral cancer has had extensive surgery to excise the malignancy. Although surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to this client and family?

time to mourn, accept, and adjust to the loss

Hickman and Groshong are examples of which type of central venous access device?

tunneled central catheters

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician?

urinary output 20 mL/hr

The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits

Which of the following appears to be a significant factor in the development of gastric cancer?

Diet

A patient who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the patient complained of cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the patient be educated about regarding this event?

Dumping syndrome

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to

Elevate the head of the bed to 45 degrees.

As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." How should the nurse intervene?

Evaluate the client's understanding of the procedure.

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Fasting blood glucose level

The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is

Flush with 10 mL of water.

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?

Gently washing the area surrounding the stoma using a facecloth and mild soap

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?

Hemorrhage

Review the following four examples of ideal body weight (IBW), actual weight, and body mass index (BMI). Using three criteria for each example, select the body weight that indicates morbid obesity.

IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2

A nurse prepares a patient for insertion of a nasoenteric tube. What position should the nurse place the patient in?

In high-Fowler's position

Which of the following is one of the first clinical manifestations of esophageal cancer?

Increasing difficulty is swallowing

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?

Indomethacin (Indocin)

Crohn's disease is a condition of malabsorption caused by which pathophysiological process?

Inflammation of all layers of intestinal mucosa

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

The client's natural bowel function may become sluggish.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration?

Keeping the client in a semi-Fowler's position at all times.

A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which of the following measures will help ease the client's discomfort?

Keeping the head of the bed elevated.

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

Nothing by mouth

Peptic ulcer disease occurs more frequently in people with which blood type?

O

Which medication classification represents a proton (gastric acid) pump inhibitor?

Omeprazole

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Polyps

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

Provide frequent mouth care.

A nurse is preparing a presentation for a local community group for older adults on nutrition and anorexia in this population. Which of the following would the nurse include in the presentation as a possible contributing factor for anorexia in the older adult?

Reduction in and atrophy of taste buds

Which of the following is the most successful treatment for gastric cancer?

Removal of the tumor

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

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

An elderly patient is diagnosed with parotitis. The nurse is aware that this bacterial infection is most likely caused by:

Staphylococcus aureus.

Which of the following are signs/symptoms of perforation?

Sudden, severe upper abdominal pain

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium (Colace) daily.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5

A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?

Uncontrolled rhythmic movements of the face or limbs

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed?

When the residual is greater than 200 mL

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition?

anal fissure

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n)

anal fissure.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:

black and tarry.

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

maintaining a patent airway.

The most common symptom of esophageal disease is

dysphagia

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. She has the following oral medications prescribed: furosemide (Lasix), digoxin, enteric coated aspirin (Ecotrin), and vitamin E. The nurse withholds

enteric coated aspirin

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?

enteric-coated tablets

Which is a true statement regarding the nursing considerations in administration of metronidazole?

leaves metallic taste in the mouth