chapter 39 prep-u medsurg

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

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? - Encourage the client to ingest a soft or bland diet. - Instruct the client to swish prescribed nystatin solution for 1 minute. - Provide saline rinses prior to meals. - Remove the plaque from the mouth by rubbing with gauze.

Gastroesophageal reflux disease

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? - Gastroesophageal reflux disease - Peptic ulcer with melena - Gastritis - Diverticulitis with perforation

Ineffective airway clearance related to obstruction by mucus

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 - Imbalanced nutrition: less than body requirements, related to treatment - impaired tissue integrity related to surgical intervention - Risk for infection related to surgical intervention - Ineffective airway clearance related to obstruction by mucus

Brush and floss daily.

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? - Use a hard-bristled toothbrush. - Continue with the usual diet. - Rinse with an alcohol-based solution. - Brush and floss daily.

nystatin

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? - Fluocinolone acetonide oral base gel - Acyclovir - Cephalexin - Nystatin

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

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. - Prepare to administer chemotherapeutics as prescribed. - Arrange for a diet that is high in protein and low in fat. - Administer colony stimulating factors (CSFs) as prescribed.

Assess lung sounds bilaterally.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? - Suction the oral cavity of the client. - Obtain consent for the esophagogastroscopy. - Assess lung sounds bilaterally. - Administer prescribed morphine intravenously.

increasing difficulty in swallowing

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? - Increasing difficulty in swallowing - Hiccups - Sensation of a mass in throat - Foul breath

assess the graft for color and temperature

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? - Administer prescribed intravenous vancomycin at the correct time. - Assess the graft for color and temperature. - Cleanse around the drain using aseptic technique. - Reinforce the neck dressing when blood is present on the dressing.

Attaches the fat emulsion tubing to a Y connector close to the infusion 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? - Stops the admixture while the fat emulsion infuses - Connects the tubing for the fat emulsion above the 1.5 micron filter - Starts a peripheral IV site to administer the fat emulsion - Attaches the fat emulsion tubing to a Y connector close to the infusion site

No land line; cell phone available and taken by family member during working hours

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance? - Little food in the working refrigerator - Water of low pressure that can be obtained through all faucets - Electricity that loses power, usually for short duration, during storms - No land line; cell phone available and taken by family member during working hours

dumping syndrome

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? - Paralytic ileus - Dumping syndrome - Small bowel obstruction - Diverticulosis

Notify the surgeon about the tube's removal.

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. - Document the discontinuation of the nasogastric tube. - Place the nasogastric tube to the level of the esophagus. - Reinsert the nasogastric tube to the stomach.

An effective means of communicating with the nurse

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 - Emotional support from visitors and staff - Referral to a speech therapist - Dietary teaching focused on consistency of food and frequency of feedings

keeping head of bed elevated

A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort? - Providing a tracheostomy tray near the bed. - Keeping the head of the bed elevated. - Turning the client's head to the side. - Positioning the client flat on the abdomen or side.

Assess patency of the NG tube.

A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first? - Assess patency of the NG tube. - Auscultate bowel sounds. - Assess vital signs. - Measure abdominal girth.

Assessing lung sounds

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by - Administering the prescribed analgesic - Assessing lung sounds - Preparing for a barium swallow - Providing fluids to drink

take long, slow breaths

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? - Pant like a dog - Take long, slow breaths - Bear down as if having a bowel movement - Hold his breath

respiratory status and airway clearance

A client with cancer of the tongue has had a radical neck dissection. What nursing assessment should the nurse prioritize? - Tissue integrity and color of the operative site - Respiratory status and airway clearance - Presence of acute pain and anxiety - Self-esteem and body image

Hairy leukoplakia

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? - Erythroplakia - Nicotine stomatitis - Hairy leukoplakia - Aphthous stomatitis

Confirm placement of the tube prior to each scheduled feeding.

A client's new onset of dysphagia has required insertion of an NG tube for feeding. What intervention should the nurse include in the client's plan of care? - Confirm placement of the tube prior to each scheduled feeding. - Keep the client in a low Fowler position when at rest. - Connect the tube to continuous wall suction when not in use. - Have the client sip cool water to stimulate saliva production.

Wipes catheter ports from distal end to insertion site

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action: - Wipes catheter ports from distal end to insertion site - Contaminates gloves and obtains a pair of sterile gloves for use - Cleanses the insertion site with a chlorhexidine solution - Uses a circular motion from insertion site outward

Auscultate lung sounds every 4 hours.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to - Apply water-based lubricant to the nares daily. - Auscultate lung sounds every 4 hours. - Change the nasal tape every 2 to 3 days. - Inspect the nose daily for skin irritation.

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

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 - Discusses with the nutritionist about increasing the osmolality of the feeding - Administers the feeding at a cooler temperature - Increases the amount of feeding at the next feeding

Approximately 80 to 120 mL

A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage? - Greater than 160 mL - Between 40 and 80 mL - Approximately 80 to 120 mL - Between 120 and 160 mL

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

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? - Foley catheter bag containing 500 ml of amber urine - Serosanguineous drainage on the dressing - The client lying in a lateral position, with the head of bed flat - A piggyback infusion of levofloxacin

explain the process clearly to the patient

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. - Apply topical anesthetic to the client's nares as prescribed. - Assist the client into a supine position. - Assess the client's appetite.

Risk for Impaired Skin Integrity Related to the Presence of NG Tube

A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan? - Risk for Excess Fluid Volume Related to Enteral Feedings - Risk for Unstable Blood Glucose Related to Enteral Feedings - Risk for Impaired Verbal Communication Related to Presence of NG Tube - Risk for Impaired Skin Integrity Related to the Presence of NG Tube

Imbalanced Nutrition: Less Than Body Requirements

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? - Ineffective Tissue Perfusion - Imbalanced Nutrition: Less Than Body Requirements - Aspiration - Impaired Skin Integrity

shakiness, tachycardia, weakness, and confusion

A nurse suspects that a client is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which assessment support the nurse's suspicion? Select all that apply. - Confusion - Weakness - Shakiness - Dry, hot skin - Tachycardia - Reports of feeling flushed

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? - Esophageal cancer - Gastroesophageal reflux disease - Diverticulitis - Peptic ulcer disease

Protrusion of the upper stomach into the lower portion of the thorax.

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): - Involution of the esophagus, which causes a severe stricture. - Extension of the esophagus through an opening in the diaphragm. - Twisting of the duodenum through an opening in the diaphragm. - Protrusion of the upper stomach into the lower portion of the thorax.

Excess fluid volume

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? - Impaired urinary elimination - Risk for imbalanced nutrition, more than body requirements - Excess fluid volume - Deficient fluid volume

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

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? - Begin an infusion of normal saline in another site to maintain hydration. - Hang a solution of dextrose 10% and water until the new solution is available. - Slow the current infusion rate so that it will last until the new solution arrives. - Have someone go to the pharmacy to obtain the new solution.

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

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 need to keep my head turned directly toward you and the health care provider." - "I'll have to wear a thick, bulky dressing over the site." - "I will need to take long, slow, deep breaths when the catheter is inserted." - "I will be lying on my back but my legs will be higher than my head."

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

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. - Test the integrity of cranial nerve XII by asking the client to protrude the tongue. - Inspect the client's gums for bleeding and hyperpigmentation. - Assess the temporomandibular joint for evidence of a malocclusion.

Exhibiting hemoglobin A1C 8.2

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 - Using a soft-bristled toothbrush - Drinking fluoridated water - Eating fruits and cheese in diet

esophageal tumor

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? - Hiatal hernia - Gastritis - Esophageal tumor - Gastroesophageal reflux disease

Staphylococcus aureus

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? - Pneumococcus - Staphylococcus aureus - Streptococcus viridans - Methicillin-resistant Streptococcus aureus (MRSA)

Vagus

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

Lithotripsy

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

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

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

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

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. - Elevate the upper body on pillows. - Avoid beer, especially in the evening. - Elevate the head of the bed on 6- to 8-inch blocks. - Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. - Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid.

Fowler

Postoperatively, a client with a radical neck dissection should be placed in which position? - Fowler - Side-lying - Supine - Prone

greater than 200mL

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was: - Greater than 200 mL. - About 50 mL. - Between 50 and 80 mL. - About 100 mL.

1 hour

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? - 30 minutes - 90 minutes - 1 hour - 2 hours

shift

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every - 24 hours. - shift. - hour. - 12 hours.

Levin tube

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? - Salem sump tube - Sengstaken-Blakemore tube - Levin tube - Miller-Abbott tube

dysphagia

The most common symptom of esophageal disease is - dysphagia. - vomiting. - odynophagia. - nausea.

Monitoring the feeding closely.

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? - Increasing the feeding rate. - Lowering the head of the bed. - Flushing the feeding tube. - Monitoring the feeding closely.

High epigastric pain and/or discomfort

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician? - Temperature of 99.0°F (37.2°C) - Crackles that clear after coughing - Serous drainage on the dressing - High epigastric pain and/or discomfort

all interventions should be added to plan of care

The nurse is caring for a client on chemotherapy who is recovering from surgery for oral cancer. Which interventions will the nurse add to this client's plan of care? Select all that apply. - Maintain a patent airway - Provide a mechanism to communicate - Ensure adequate nutritional intake - Prevent the development of stomatitis - Prevent infection

client is comatose & enteral support needed for over 6 weeks

The nurse is caring for a client who requires enteral nutrition. For which reasons will the nurse anticipate the client having a gastrostomy tube inserted? Select all that apply. - Enteral support needed for over 6 weeks - Hyperactive bowel sounds - Client is comatose - Frequent bouts of constipation - History of diverticulosis

Boerhaave syndrome

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? - Periapical abscess - Boerhaave syndrome - Zenker diverticulum - Halitosis

baking soda and water

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? - Dextrose and water - Mouthwash and water - Baking soda and water - Full-strength peroxide

Administer prescribed metoclopramide.

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? - Have the client lay on the left side. - Administer prescribed metoclopramide. - Instruct the client to swallow several times. - Assist the client to drink 8 ounces of water.

Notify the physician

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? - Administer a breathing treatment - Lower the head of the bed - Document the presence of stridor - Notify the physician

catheter hub

The primary source of microorganisms for catheter-related infections are the skin and which of the following? - IV tubing - Catheter tubing - Catheter hub - IV fluid bag

organic fruit juice

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. - roasted nuts. - cheddar cheese. - red meat that is high in fat.

"Avoid coffee and alcoholic beverages."

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? - "Take antacids with meals." - "Avoid coffee and alcoholic beverages." - "Lie down after meals to promote digestion." - "Limit fluid intake with meals."

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

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? - Remove the catheter, check for catheter integrity, and send the tip for culture. - Notify the physician. - Remove the dressing, clean the site, and apply a new dressing. - Draw a circle around the moist spot and note the date and time.

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

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? - Administering 15 to 30 mL of water every 4 hours. - Giving the feedings at room temperature. - Keeping the client in a semi-Fowler's position at all times. - Aspirating for residual contents every 4 to 8 hours.

bradycardia

Which clinical manifestation is not associated with hemorrhage? - Tachypnea - Tachycardia - Hypotension - Bradycardia

difficulty swallowing

Which is the primary symptom of achalasia? - Difficulty swallowing - Heartburn - Pulmonary symptoms - Chest pain

Weakness, diaphoresis, diarrhea 90 minutes after eating

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? - Abdominal distention, elevated temperature, weakness before eating - Persistent loose stools, chills, hiccups after eating - Weakness, diaphoresis, diarrhea 90 minutes after eating - Constipation, rectal bleeding following bowel movements

Zenker's diverticulum

Which of the following is the most common type of diverticulum? - Intramural - Epiphrenic - Zenker's diverticulum - Mid-esophageal

Metoclopramide (Reglan)

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? - Metoclopramide (Reglan) - Nizatidine (Axid) - Famotidine (Pepcid) - Esomeprazole (Nexium)

chancre

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? Leukoplakia Chancre Lichen planus Actinic cheilitis

Sialolithiasis

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? - Parotitis - Sialolithiasis - Sialadenitis - Stomatitis

4

s 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? 6 4 8 10