Chapter 39: Management of Patients with Oral and Esophageal Disor

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

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?

260

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?

6

A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time?

An effective means of communicating with the nurse

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?

Apply pressure to the bleeding site

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

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.

Which clinical manifestation is not associated with hemorrhage?

Bradycardia

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?

Clean the port with an alcohol pad before administering I.V. fluid through the catheter.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.

Daily weights Intake and output monitoring Calorie counts for oral nutrients

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?

Dumping syndrome

When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention?

Elevate the head of the bed 90 degrees during meals.

A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action?

Explain the process clearly to the client.

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

Fasting blood glucose level

The nurse 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

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

Postoperatively, a client with a radical neck dissection should be placed in which position?

Fowler

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?

Gastroesophageal reflux disease

A patient is experiencing painful, inflamed, and swollen gums, and when brushing the teeth, the gums bleed. What common disease of the oral tissue does the nurse understand these symptoms indicate?

Gingivitis

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?

Increasing difficulty in swallowing

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

Lithotripsy

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.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal.

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions?

Prevent aspiration

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?

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

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

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

A client with cancer of the tongue has had a radical neck dissection. What nursing assessment should the nurse prioritize?

Respiratory status and airway clearance

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

Staphylococcus aureus

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

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?

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

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication?

enteric coated aspirin

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:

greater than 200

The nurse provides health teaching to inform the client with oral cancer that

many oral cancers produce no symptoms in the early stages

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:

there are usually no symptoms.