Exam 4 - Chapter 22 Patients with Oral & Esophageal Disorders

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

"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

A nurse is interviewing a patient to determine suitability for home parenteral nutrition. Which patient statement would alert the nurse to a potential problem? "I have a telephone, but it has been shut off because my bill is overdue." "My son and daughter live just down the block, and my wife is home all day." "I'm willing to learn new things, so I can be as independent as possible." "I live in a one-story house with lots of closets and cabinets."

"I have a telephone, but it has been shut off because my bill is overdue." Lack of access to a working telephone would be a concern because a telephone is necessary for contacting home health personnel, arranging for prompt delivery of supplies, and emergency purposes. Available family support, a willingness to learn, a desire for self-sufficiency, and a physical home environment with adequate storage for supplies and a lack of obstacles that might hinder the patient's mobility are important to the success of home parenteral nutrition.

The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do? stop the infusion and flush the line hang normal saline with potassium hang 10% dextrose and water hang 5% dextrose and water

hang 10% dextrose and water If the parenteral nutrition (PN) solution runs out and no PN is available, the nurse should hang 10% dextrose and water until the PN becomes available.

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 .symptoms include mouth pain. symptoms include oral bleeding. symptoms include oral numbness.

there are usually no symptoms The early stage of oral cancer is characteristically asymptomatic.

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

1 hour

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance? ____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.

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 Baking soda and water Full-strength peroxide Mouthwash and water

Baking soda and water

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number. ____ hours

6 hours Step 1:2 × 8 oz = 16 oz Step 2:1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours

The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings? Aphthous stomatitis Kaposi's sarcoma Chancre Hairy leukoplakia

Aphthous stomatitis Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.

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? Between 40 and 80 mL Approximately 80 to 120 mL Between 120 and 160 mL Greater than 160 mL

Approximately 80 to 120 mL Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.

A patient with a recent diagnosis of esophageal cancer has undergone an esophagectomy and is currently receiving care in a step-down unit. The nurse in the step-down unit is aware of the specific complications associated with this surgical procedure and is consequently monitoring the patient closely for signs and symptoms of: Increased intracranial pressure (ICP) Aspiration pneumonia Abdominal aortic aneurysm (AAA) Dyspepsia

Aspiration pneumonia Aspiration pneumonia is a common, and dangerous, post-operative complication following esophagectomy. Increased ICP and AAA are not commonly associated with the procedure, and dyspepsia is not a high-priority concern.

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

Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

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. Inspect the nose daily for skin irritation. Change the nasal tape every 2 to 3 days.

Auscultate lung sounds every 4 hours. Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Consume foods containing peppermint or spearmint. Avoid eating or drinking 2 hours before bedtime. Elevate the foot of the bed on 6- to 8-inch blocks. Eat a low-carbohydrate diet.

Avoid eating or drinking 2 hours before bedtime. The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head of the bed on 6- to 8-inch blocks.

A nurse is preparing to assist a health care provider with a peripherally inserted central catheter. The nurse demonstrates understanding of this procedure by preparing which insertion site? Subclavian vein Basilic vein Jugular vein Metacarpal vein

Basilic vein Peripherally inserted central catheters are inserted using the basilic or cephalic veins above the antecubital space. The subclavian vein is used for nontunneled central catheters. The jugular vein is used for nontunneled central catheters only as a last resort. The metacarpal vein is used for routine intravenous therapy.

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

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 is an accurate statement regarding cancer of the esophagus? It is three times more common in women than men in the United States . It is seen more frequently in European Americans than in African Americans. It usually occurs in the fourth decade of life. Chronic irritation of the esophagus is a known risk factor.

Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men than in women. It is seen more frequently in African Americans than in European Americans. It usually occurs in the fifth decade of life.

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

Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

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

Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

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 Diverticulitis with perforation Gastritis

Gastroesophageal reflux disease Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? Helping the client cope with body image changes Ensuring adequate nutrition Maintaining a patent airway Preventing injury

Maintaining a patent airway Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: Make a notation on the call light system that the client cannot speak. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. Provide oxygen without humidity through the tracheostomy tube. Encourage the client to position himself on his side.

Make a notation on the call light system that the client cannot speak. The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

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? No land line; cell phone available and taken by family member during working hours Water of low pressure that can be obtained through all faucets Little food in the working refrigerator Electricity that loses power, usually for short duration, during storms

No land line; cell phone available and taken by family member during working hours A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.

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? Nystatin Cephalexin Fluocinolone acetonide oral base gel Acyclovir

Nystatin Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

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): Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm.

Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

Which term describes an inflammation of the salivary glands? Parotitis Sialadenitis Stomatitis Pyosis

Sialadenitis

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding? Parotitis Sialadenitis Stomatitis Pyosis

Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

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

Sialolithiasis

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

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).

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

Take long, slow breaths 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 nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes? The tube is radiopaque. The tube is shorter. The tube is less expensive. The tube can be connected to suction and others cannot.

The tube is radiopaque.

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

Vagus Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? When the residual is about 50 mL When the residual is between 50 and 80 mL When the residual is about 100 mL When the residual is greater than 200 mL

When the residual is greater than 200 mL Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.

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. manifestations of electrolyte disturbances. manifestations of hypoglycemia. constipation, dehydration, and hypercapnia.

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.

A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing pyrosis. dyspepsia. dysphagia. odynophagia.

pyrosis. Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.

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

Provide the client with an irrigating solution of baking soda and warm water. 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.

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

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 managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement.

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

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? Palpate the patient's parotid glands to detect swelling and tenderness. Assess the temporomandibular joint for evidence of a malocclusion. Test the integrity of the 12th cranial nerve by asking the patient to protrude his tongue. Inspect the patient's gums for bleeding and hyperpigmentation.

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

Total parenteral nutrition (TPN) has been ordered for a male patient who has been experiencing a severe and protracted exacerbation of Crohn's disease. Before TPN can be initiated, the patient requires: A random blood glucose level of ≤160 mg/dL Angiography to determine the patency of his vascular system The insertion of a central venous access device A fluid challenge to assess his renal function

The insertion of a central venous access device Because of its high osmotic pressure, TPN may only be administered through a central line. Its use does not directly depend on renal function or specific blood glucose levels. Angiography is not required before the initiation of TPN.

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280ml The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse? A canker sore of the oral soft tissues An acute stomach infection Acid indigestion An early sign of peptic ulcer disease

A canker sore of the oral soft tissues Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

A nurse is aware that even though tube feedings are generally well-tolerated by most patients, there is a still a risk of dumping syndrome. Which of the following actions has the greatest potential to reduce a patient's risk of experiencing dumping syndrome? Administering feedings at a low, continuous rate rather than by bolus Administering diuretics prior to initiating a feeding Diluting feedings at a 1:2 ratio of feedings to water Administering feedings with the patient in a supine position to slow motility

Administering feedings at a low, continuous rate rather than by bolus

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? Assess lung sounds bilaterally. Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

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

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.

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? Cranberry juice Air insufflation Digestive enzyme mixed with warm water Commercial enzyme product

Cranberry juice To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube.

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Hiatal hernia Gastroesophageal reflux disease Gastritis Esophageal tumor

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 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? Excess fluid volume Risk for imbalanced nutrition, more than body requirements Deficient fluid volume Impaired urinary elimination

Excess fluid volume The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Remove the tape from the nose of the client. Withdraw the tube gently for 6 to 8 inches. Provide oral hygiene. Flush with 10 mL of water.

Flush with 10 mL of water. Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient? Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.

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

Increasing difficulty in swallowing

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Buccal Parotid Sublingual Submandibular

Parotid

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

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

The nurse is checking placement of a nasogastric (NG) tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate? The tube is in the pleural space. The tube is the intestine. The tube is in the stomach. The tube is in the esophagus.

The tube is in the stomach. The patient's aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Clear, yellow, and bile-colored are associated with intestinal aspirate. Tan mucus is associated with tracheobronchial secretions, and pleural secretions are pale yellow.

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: Cleanses the insertion site with a chlorhexidine solution Uses a circular motion from insertion site outward Wipes catheter ports from distal end to insertion site Contaminates gloves and obtains a pair of sterile gloves for use

Wipes catheter ports from distal end to insertion site Proper cleansing of a CVAD includes cleaning the insertion site with a chlorhexidine solution in a circular motion from insertion site outward. The nurse will obtain another pair of sterile gloves to perform the procedure if contamination of gloves occurs. The nurse cleanses from insertion site outward to distal catheter ports.

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

esophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. 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 client is on a continuous tube feeding. The nurse determines the tube placement should be checked every shift. hour. 12 hours. 24 hours.

shift. Each nurse caring for the client is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the client is extremely restless or there is basis for rechecking the tube due to other client activities. Checking for placement every 12 or 24 hours does not meet the standard of care for the client receiving continuous tube feedings.

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? 1 2 4 6

6 Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? Discontinue the infusion. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding.

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? Place the client in the Fowler's position. Administer morphine for report of pain. Provide feeding through the gastrostomy tube. Empty the Jackson-Pratt device (portable drainage device).

Place the client in the Fowler's position. All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.

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? Halitosis Zenker diverticulum Boerhaave syndrome Periapical abscess

Boerhaave syndrome Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

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. Positioning the client flat on the abdomen or side. Providing a tracheostomy tray near the bed. Turning the client's head to the side.

Keeping the head of the bed elevated. It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.

A 54 year-old man is postoperative day 1 following neck dissection surgery. Which of the following nursing actions should the nurse prioritize in the care of this patient? Teaching the patient about the signs and symptoms of major postoperative complications Positioning the patient in a high Fowler's position to protect the airway Ensuring that naloxone (Narcan) is available at the patient's bedside Maintaining protective isolation for 24 to 36 hours after surgery

Positioning the patient in a high Fowler's position to protect the airway Protection of the patient's airway is a priority over patient education, even though patient education is an appropriate and relevant measure. It is not normally necessary to keep naloxone at the bedside or to establish protective isolation.

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? 4 p.m. to 6 p.m. 6 p.m. to 8 p.m. 8 p.m. to 10 p.m. 10 p.m. to 12 a.m.

6 p.m. to 8 p.m. The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m

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? Assess lung sounds bilaterally. Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

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? A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process The distance determined by measuring from the tragus of the ear to the xiphoid process

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.

Hickman and Groshong are examples of which type of central venous access device? implanted ports tunneled central catheters peripherally inserted central catheters nontunneled central catheters

tunneled central catheters Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A peripherally inserted central catheter (PICC) line is used for intermediate-term IV therapy for the hospital, long-term care, or the home setting.

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? Spray the oropharynx with an anesthetic spray. Have the patient maintain a backward tilt head position. Allow the patient to sip water as the tube is being inserted. Have the patient eat a cracker as the tube is being inserted.

Allow the patient to sip water as the tube is being inserted. 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.

The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient? Avoid applying suction on or near the graft site. Position patient on his nonoperative side with the head of the bed down. Assess viability of the graft before beginning suctioning. Evaluate the patient's ability to swallow saliva and clear fluids.

Avoid applying suction on or near the graft site. The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patient's ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patient's need for suctioning.

A nurse is conducting morning assessments of several medical patients and has entered the room of a patient who has a nasogastric (NG) tube in situ. Immediately, the nurse observes that the tube has become unsecured from the patient's nose and the mark at the desired point of entry is now approximately 8 inches from the patient's nose. How should the nurse best respond to this assessment finding? Reinsert the NG tube and arrange for x-ray confirmation of placement. Remove the NG tube and obtain an order for reinsertion. Reinsert the NG tube and monitor the patient closely for signs of aspiration. Reinsert the NG tube and aspirate stomach contents to confirm correct placement.

Reinsert the NG tube and arrange for x-ray confirmation of placement. If the patient's NG tube becomes unsecured, placement should be reconfirmed; the most accurate form of confirmation is an x-ray.

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? Aphthous stomatitis Nicotine stomatitis Erythroplakia Hairy leukoplakia

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 patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? 5-mL 10-mL 20-mL 30-mL

30-mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.

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

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

The nurse caring for a patient who is being discharged home after a radical neck dissection has worked with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? Indicates acceptance of altered appearance and demonstrates positive self-image Freely expresses needs and concerns related to postoperative pain management Compensates effectively for alteration in ability to communicate related to dysarthria Demonstrates effective stress management techniques to promote muscle relaxation

Indicates acceptance of altered appearance and demonstrates positive self-image Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patient's appearance is visibly altered. The face generally appears asymmetric with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patient's level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation.

A 59-year-old woman with a recent history of heartburn, regurgitation, and occasional dysphagia has been diagnosed with a sliding hiatal hernia following an upper GI series. The nurse is providing patient education about the management of this health problem. What should the nurse suggest as a management strategy to this patient? Minimizing her intake of highly spiced foods and dairy products Remaining upright for at least 1 hour following each meal Abstaining from alcohol Drinking one to two glasses of water before and after each meal

Remaining upright for at least 1 hour following each meal Management for a sliding hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Fluid intake is encouraged, but this should be ingested throughout a meal, not just before and after the meal. It is not necessary to refrain from drinking alcohol, spicy foods, or dairy products.

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method? X-ray visualization Measurement of exposed tubing pH measurement of aspirate Air auscultation

X-ray visualization X-ray visualization of the tube tip is the most accurate method to verify placement; however, it is also the most expensive method and exposes the patient to radiation doses. Measuring the length of the exposed tubing only provides information about the position, not the location, of the tip. Testing the pH of the aspirate helps to distinguish between gastric and intestinal placement. This method also can be affected by interventions such as the use of antacids or continuous tube feedings. Air auscultation is highly variable, and normal bowel and bronchial sounds may interfere with interpretation.

The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding at a warm temperature to decrease peristalsis. Administer the feeding by bolus to prevent continuous intestinal distention. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.

Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, not at a warm temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated), rather than by bolus, to prevent sudden distention of the intestine. Instill the minimal amount of water needed to flush the tubing before and after a feeding, not to dilute the formula but because fluid given with a feeding increases intestinal transit time.

An older woman has been receiving enteral feeds by nasogastric (NG) tube for the past several days due to a decrease in her level of consciousness. How can the nurse best assess the patient's tolerance of the current formula and rate of delivery? Carefully document the number and consistency of bowel movements. Aspirate and measure the stomach contents on a regular basis. Monitor the patient's skin turgor and the color of her sclerae. Perform regular chest auscultation and monitor her oxygen saturation levels.

Aspirate and measure the stomach contents on a regular basis. Patient tolerance of liquid enteral nutrition is determined by residual measurement. The volume of aspirate indicates the rate at which the patient is digesting the feedings and how quickly the chyme is passing into the small intestine. Respiratory assessment is important because of the risk of aspiration, but doing so does not necessarily determine tolerance of the feeds. Skin turgor is not an accurate assessment in older adults. Bowel patterns are a significant assessment, but these do not necessarily indicate tolerance or a lack thereof.

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 Starts a peripheral IV site to administer the fat emulsion Attaches the fat emulsion tubing to a Y connector close to the infusion site Connects the tubing for the fat emulsion above the 1.5 micron filter

Attaches the fat emulsion tubing to a Y connector close to the infusion site An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.

The nurse attempts to unclog a client's feeding tube. Attempts with warm water agitation and milking the tube are unsuccessful. The nurse uses evidence-based practice principles when subsequently using which technique to unclog the tube? digestive enzymes and sodium bicarbonate cola mixed with cranberry juice sodium bicarbonate mixed with water meat tenderizer diluted with saline

digestive enzymes and sodium bicarbonate The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable.

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply. Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Induce vomiting to remove the base solution from the stomach. Assess respiratory status every 4 hours and prn.

Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Assess respiratory status every 4 hours and prn The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.

The patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? Prime the tubing with 20 mL of normal saline. Keep the vent lumen above the patient's stomach level. Maintain the patient in a high Fowler's position. Have the patient pin the tube to the thigh.

Keep the vent lumen above the patient's stomach level. The blue vent lumen should be kept above the patient's stomach to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way antireflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, you do not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? "It is a vent that prevents backflow of the secretions." "It acts as a siphon, pulling secretions into the clear tubing." "It helps regulate the pressure on the suction machine." "It works as a marker to make sure that the tube stays in place."

"It is a vent that prevents backflow of the secretions." The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.