MedSurg Chapter 45

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?

Esophageal tumor

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?

Gastrostomy tube

A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?

Give high-protein, semiliquid foods.

The client is concerned about hair loss while receiving chemotherapy. Which is the best response from the nurse in explaining chemotherapy-induced alopecia?

Hair loss is temporary.

Following abdominal surgery, excessive drainage from the client's nasogastric tube is observed. Which assessment finding is most likely to occur?

Metabolic alkalosisópH 7.52, PaCO2 35 mm Hg, HCO3 28 mEq/L

A client, who has occasional gastric symptoms, is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?

"Eliminating bothersome foods will help."

After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching?

"I need to drink 8 oz of water before eating."

A client is scheduled for a gastrojejunostomy as a surgical treatment of chronic peptic ulcer disease. The client asks the nurse to explain the stump left behind. Which is the best explanation provided by the nurse?

"Keeping the stump aids in digestion."

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

The nurse is checking the residual content for a client who is receiving intermittent feedings. Which residual content, if obtained, would lead the nurse to delay the feeding?

120 mL

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?

6 hours

Which nursing interventions are primary in the care of a client receiving internal sealed radiation? Select all that apply. A) Time, distance, and shielding B) Count wires/threads every shift. C) Maintain ink markings on the skin. D) Administer treatments through the intravenous port. E) Provide rest periods between treatments. F) Encourage family involvement in direct care.

A, B

The nurse is caring for a young woman who is struggling with weight loss issues, without apparent physical cause. Which is the most likely nursing assessment for this nutritional disorder in which normal body weight is not maintained?

Anorexia nervosa

The nurse is evaluating the medication list of a client with acute gastritis. Which medication would create the most concern?

Anti-arthritis medication (Advil)

The client is scheduled for external beam radiation for the treatment of an upper gastrointestinal cancer. Which is the most significant factor in the nursing care of this client?

Avoid washing off markings.

A client is being evaluated for an esophageal tumor. Which nursing assessment finding presents the greatest concern?

Back pain

which of the following actions by the nurse promotes safety for a client receiving bolus to feedings via a nasogastric tube? SATA A) administer the tube feeding within 10 minutes B) after feeding, aspirate gastric contents and test the pH of the aspirate C) assess to placement according to agency policy D) check the residual volume prior to the bolus feeding E) irrigate the nasogastric tube with 30 mL of water following the bolus.

C, D, E

A distressed obese teenager has attempted suicide due to peer ridicule and teasing. Which nursing diagnosis is of primary concern for this client?

Disturbed Body Image

The client is ordered cimetidine (Tagamet) H2-receptor antagonist agent for the short-term management of gastroesophageal reflux disease (GERD). Which of the following assessment findings is most important in determining care of this client?

Elevation of liver enzymes

The nurse is holding a teaching workshop on managing the symptoms of hiatal hernia in the elderly. Which of the following lifestyle modifications should be included in the presentation?

Eliminating tobacco use

An elderly client presents with a complaint of 10-lb weight loss over the past month. Which assessment finding is most important in determining the care of this client?

History of COPD

A client, who is recovering from bariatric surgery, is returning from the postanesthesia care unit. Which nursing assessment is of greatest concern in the immediate postoperative period for this client?

Impaired Gas Exchange

Which of the following interventions would be most appropriate for a client with a hiatal hernia and nursing diagnosis of Acute Pain related to reflux of gastric secretions?

Inform the client to remain upright for at least 2 hours after meals.

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.

The plan of care for the cancer client includes weekly blood counts. Changes in which of the following laboratory values would be the most likely reason for an order of filgrastim (Neupogen) injection?

Leukopenia

In caring for a client immediately following gastric cancer surgery, which nursing assessment finding would require priority attention?

Levine tube set to high continuous suction

The nurse is counseling an adolescent who has a body mass index of 33%. Which of the following complications is of greatest concern?

Lifelong obesity

Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Measure pH of aspirates

A client with a history of peptic ulcer disease is admitted for hematemesis associated with gastric bleeding. Which is the most appropriate action of the nurse?

Prepare for nasogastric irrigations.

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?

Prochlorperazine (Compazine)

The client receiving radiotherapy complains of increased fatigue. The nurse understands that the most significant reason for this symptom is related to which factor?

Radiation suppresses red blood cell production.

A client with peptic ulcer disease is scheduled for a partial gastrectomy and vagotomy. The nurse understands the surgery will accomplish which of the following physiologic effects?

Remove source of acid secretion.

A client with peptic ulcer disease complains of sharp mid-epigastric pain. Which assessment finding is most important to the care of this client?

Rigid abdomen

A client with complaints of nausea and vomiting has been ordered a nasogastric tube insertion. Which action should the nurse take first once the NG tube is inserted?

Secure the NG tube and assess drainage.

The wound care nurse suspects a nutritional problem with a client who presents with weight loss, poor appetite, and delayed healing. Which of the following laboratory findings would be most indicative of a nutritional problem?

Serum albumin level 2 g/dL

A client is preparing for discharge to home, following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?

Slows gastric emptying

A client with bacterial infection is suspected of suffering from malnutrition. Which nursing assessment finding would be most significant in evaluating this client?

Total lymphocyte count (TLC)

In a client receiving radiation therapy to the head, prevention of infection of the teeth and gums is important. Which is the primary nursing care measure that should be taken?

Use of topical antiseptic mouthwash

A client has undergone a total gastrectomy for refractory ulcers. The nurse would explain the need for lifelong treatment with which of the following?

Vitamin B12 replacement

A client is prescribed a magnesium and aluminum hydroxide antacid to treat gastroesophageal reflux disease (GERD). The nurse cautions this client to do which of the following?

Watch for possible antacid-related diarrhea.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating

The nurse needs to administer feedings to a client who has diarrhea due to gastroenteritis period which of the following factors should the nurse consider?

administer feedings at room temperature

Which nursing actions will ensure two placement and decrease the risk of bacterial infection as well as crusting or blockage of the tube?

administering 15 to 30 mL of water before and after medications and feedings.

The nurse assists the client experiencing nausea and vomiting to develop tolerance for fluids and foods. which of the following nursing actions would help the client?

advancing the diet slowly

The nurse is monitoring a client diagnosed with peptic ulcer disease for any signs of medical complications. which of the following assessment measures is the most useful?

assessing the vital signs and fluid status

A nurse is preparing an intervention plan for an older client who underwent esophageal surgery. the client frequently reports problems of gastric distension period which of the following aspects will be the most essential in the client's intervention plan?

avoiding oral nourishment until bowel sounds resume and are active

A nurse is preparing an intervention plan for a client who is receiving tube feedings after an oral surgery period which of the following measures can prevent improper infusion and assist in preventing vomiting?

checking the tube placement and gastric residual prior to feedings

A client has been experiencing difficulty swallowing and undergoes esophagoscopy, which reveals that the client has a structure near the end of the client's esophagus. to help improve the client's ability to swallow, the best recommendation the nurse can make is to instruct the client to do which of the following?

chew everything very thoroughly

A client has diarrhea due to a high carbohydrate and electrolyte content of the fluid in the tube feeding period which of the following nursing actions will be most appropriate?

consulting The physician about decreasing the infusion rate

the nurse is assisting a client following an episode of severe vomiting and dehydration. the client is now tolerating fluids. what food choice suggested by the nurse is most appropriate as the client progresses with the diet?

dry toast

After esophageal surgery, a client exhibited the symptoms of dyspnea. what should a nurse do to minimize dyspnea?

ensure frequent, small meals and discourage lying down immediately after eating

the nurse reviews the results of diagnostic tests for a client experiencing persistent indigestion, feeling of gastric fullness, and unexplained weight loss period which finding best suggests that the client's symptoms are related to cancer of the stomach?

gastric analysis shows absence of hydrochloric acid

The nurse needs to promote an easy passage of food to the stomach and an obese elderly client with hiatal hernia. which of the following nursing actions in the care plan would help the client?

instructing to eat slowly and chew the food thoroughly

the nurse implements the teaching plan on dumping syndrome for the client who has recently undergone a gastrojejunostomy. after the nurse provides information about restricting carbohydrates, which additional information should the nurse plan to teach this client to help reduce the potential for experiencing the symptoms of dumping syndrome?

lie down for a short time after eating

during a routine home visit, a client describes what the nurse believes may be symptoms related to a hiatal hernia period which modification to the client's bed is most appropriate to recommend at this time?

raise the head of the bed on 4-in blocks