Ch 22 - Pts w/ Oral & Esophageal Disorders; Pts Receiving Gastrointestinal Intubation, Enteral, & Parenteral Nutrition

A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first? Summon assistance Elevate the head of the patient's bed Notify the surgeon to repair the vessel Apply pressure to the bleeding site

Apply pressure to the bleeding site

A positive nitrogen balance indicates which condition? Starvation Burn injury Tissue growth Fever

Tissue growth

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? Uncontrolled rhythmic movements of the face or limbs Dry mouth not relieved by sugar-free hard candy Hyperactivity Anxiety or irritability

Uncontrolled rhythmic movements of the face or limbs

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." "Limit fluid intake with meals." "Take antacids with meals."

"Avoid coffee and alcoholic beverages."

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?

280 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? An acute stomach infection A canker sore of the oral soft tissues An early sign of peptic ulcer disease Acid indigestion

A canker sore of the oral soft tissues

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate? Gastroesophageal reflex disease Diffuse spasm Achalasia Hiatal hernia

Achalasia

A nurse is performing an assessment for a client who presents to the clinic with an erythemic, fissuring lip lesion with white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? Sialadenitis Actinic cheilitis Human papillomavirus lesion Frey syndrome

Actinic cheilitis

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse Maintains a gauze dressing over the site for 3 days Administers an initial bolus of 50 mL water Pushes the stabilizing disk firmly against the skin Immediately starts the prescribed tube feeding

Administers an initial bolus of 50 mL water

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 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 Starts a peripheral IV site to administer the fat emulsion

Attaches the fat emulsion tubing to a Y connector close to the infusion site

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? Commercial enzyme product Cranberry juice Air insufflation Digestive enzyme mixed with warm water

Cranberry juice

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. Hypertension Tachycardia Diaphoresis Diarrhea Decreased bowel sounds

Diarrhea Tachycardia Diaphoresis

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply. Instruct the client to eat slowly and chew the food thoroughly. Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Encourage the client to eat later in the day before bedtime rather than early in the morning.

Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly.

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 Deficient fluid volume Excess fluid volume Risk for imbalanced nutrition, more than body requirements

Excess fluid volume

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

Fowler

A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document? Hairy leukoplakia Nicotine stomatitis Erythroplakia Aphthous stomatitis

Hairy leukoplakia

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? Have someone go to the pharmacy to obtain the new solution. Slow the current infusion rate so that it will last until the new solution arrives. 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.

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

A patient with a small bowel obstruction has had a Levin tube inserted and is admitted to a medical unit. The nurse who is caring for this patient is now checking that the wall suction settings are correct and should anticipate which of the following settings? Continuous low suction Intermittent high suction Continuous high suction Intermittent low suction

Intermittent low suction

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? Keep the vent lumen above the patient's stomach level. Prime the tubing with 20 mL of normal saline. Have the patient pin the tube to the thigh. Maintain the patient in a high Fowler's position.

Keep the vent lumen above the patient's stomach level.

The nurse is managing the care of a client needing gastrointestinal suction and decompression with a Levin tube. Place the steps of initiating suction and decompression in the order the nurse should perform them. Insert the gastric decompression tube. Connect the decompression tube to the suction. Locate the suction source. Select suction according to health care provider prescription.

Locate the suction source. Select suction according to health care provider prescription. Insert the gastric decompression tube. Connect the decompression tube to the suction.

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 Document the presence of stridor Notify the physician Lower the head of the bed

Notify the physician

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 Fluocinolone acetonide oral base gel Cephalexin Acyclovir

Nystatin

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? Positioning the patient in a high Fowler's position to protect the airway Maintaining protective isolation for 24 to 36 hours after surgery Teaching the patient about the signs and symptoms of major postoperative complications Ensuring that naloxone (Narcan) is available at the patient's bedside

Positioning the patient in a high Fowler's position to protect the airway

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? 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. Urge the client to regularly rinse the mouth with tap water.

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

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. Reinsert the NG tube and aspirate stomach contents to confirm correct 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 arrange for x-ray confirmation of placement.

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

Sialadenitis

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Change the tube feeding container , tubing , and adjust patient head of bed. Administer 15 to 30 mL of water before and after medications and feedings. Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Avoid cessation of feedings and adjust patient head of bed.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

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? hang normal saline with potassium stop the infusion and flush the line hang 5% dextrose and water hang 10% dextrose and water

hang 10% dextrose and water

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician? blood pressure 118/72 urinary output 20 mL/hr moist mucous membranes heart rate of 100

urinary output 20 mL/hr

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is unmeasurable alkaline acidic neutral

acidic

The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state "Most oral cancers are painful at the outset." "Blood testing is used to diagnose oral cancer." "Many oral cancers produce no symptoms in the early stages." "A typical lesion is soft and craterlike."

"Many oral cancers produce no symptoms in the early stages."

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120

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

Catheter hub

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

Make a notation on the call light system that the client cannot speak.

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

Monitoring the feeding closely. **High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.

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) Streptococcus viridans Pneumococcus Staphylococcus aureus

Staphylococcus aureus

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education? Chemotherapeutic agents Radiation therapy A low-residue diet Surgical removal of the diverticulum

Surgical removal of the diverticulum

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process A point that equals the distance from the nose to the xiphoid process The distance determined by measuring from the tragus of the ear to the xiphoid process A length of 50 cm (20 in)

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a tunneled central catheter. peripherally inserted central catheter . implanted port. nontunneled central catheter.

nontunneled central catheter.

The most significant complication related to continuous tube feedings is the interruption of GI integrity. the increased potential for aspiration. an interruption in fat metabolism and lipoprotein synthesis. a disturbance of intestinal and hepatic metabolism.

the increased potential for aspiration.

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance? Input : 710 mL Output : 450 mL

260 mL

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? Peptic ulcer disease Gastroesophageal reflux disease Diverticulitis Esophageal cancer

Gastroesophageal reflux disease

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? Remove the aspirated fluid and do not reinstill. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Dilute the gastric tube feeding solution with water and continue the feeding. Discontinue the infusion.

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine? Posterior segment of the tongue near the uvula Dorsum of the tongue Roof of the mouth next to the incisors Buccal mucosa next to the upper molars

Buccal mucosa next to the upper molars

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? Eating fruits and cheese in diet Exhibiting hemoglobin A1C 8.2 Using a soft-bristled toothbrush Drinking fluoridated water

Exhibiting hemoglobin A1C 8.2

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? Fluid volume deficit A cardiac dysrhythmia Pulmonary complications Mucous membrane irritation

Fluid volume deficit

A client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition? Impaired ability to absorb food Unwilling to ingest nutrients orally Insufficient oral intake Prolonged preoperative nutritional needs

Impaired ability to absorb food

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? Freely expresses needs and concerns related to postoperative pain management Indicates acceptance of altered appearance and demonstrates positive self-image Demonstrates effective stress management techniques to promote muscle relaxation Compensates effectively for alteration in ability to communicate related to dysarthria

Indicates acceptance of altered appearance and demonstrates positive self-image

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is Coiling in the client's mouth Passing into the esophagus Irritating the epiglottis Inserted into the lungs

Inserted into the lungs

A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. Skin antiseptic Sterile gauze pads Extension set tubing Alcohol wipes Clean gloves Masks

Masks Skin antiseptic Alcohol wipes Sterile gauze pads

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

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

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

Parotid

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

dysphagia.

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. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client. Administer prescribed morphine intravenously.

Assess lung sounds bilaterally.

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? Cleanse around the drain using aseptic technique. 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.

Assess the graft for color and temperature.

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

Auscultate lung sounds every 4 hours.

A 26-year-old man experienced severe burns in an industrial accident and has been admitted to the burn unit of a tertiary care hospital. In the days since the accident, the care team has been pleased with the trajectory of the man's recovery, and they estimate that he will require parenteral nutrition for 2 to 3 months. Which of the following access devices is most likely appropriate for this patient's nutritional needs? Peripherally inserted central catheter (PICC) Nontunneled central catheter Implanted port Tunneled central catheter

Peripherally inserted central catheter (PICC)

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 fluid challenge to assess his renal function Angiography to determine the patency of his vascular system A random blood glucose level of ≤160 mg/dL The insertion of a central venous access device

The insertion of a central venous access device

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

Weakness, diaphoresis, diarrhea 90 minutes after eating

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

Approximately 80 to 120 mL

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. Perform regular chest auscultation and monitor her oxygen saturation levels. Aspirate and measure the stomach contents on a regular basis. Monitor the patient's skin turgor and the color of her sclerae.

Aspirate and measure the stomach contents on a regular basis.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus and has been admitted to a medical unit. The nurse is writing a care plan for this patient. What information is essential to include? Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in his stools and should not cause concern. Antacids may be discontinued when symptoms of heartburn subside He will need to undergo an upper endoscopy every 6 months to detect malignant changes.

He will need to undergo an upper endoscopy every 6 months to detect malignant changes.

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

Zenker's diverticulum

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? meat tenderizer diluted with saline digestive enzymes and sodium bicarbonate cola mixed with cranberry juice sodium bicarbonate mixed with water

digestive enzymes and sodium bicarbonate

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a low-fat diet pantoprazole elevation of upper body on pillows metoclopramide

metoclopramide

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.

Assess patency of the NG tube