Chapter 45: Management of Patients with Oral and Esophageal Disorders

A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care? • Risk for Aspiration Related to Inhalation of Gastric Contents • Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption • Risk for Decreased Cardiac Output Related to Vasovagal Response • Risk for Impaired Verbal Communication Related to Oral Trauma

Ans: A Feedback: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the patients nutritional status and does not affect cardiac output or communication.

The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay? • Organic fruit juice • Roasted nuts • Red meat that is high in fat • Cheddar cheese

Ans: A Feedback: Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.

A nurse is caring for a patient who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite? • Encourage the family to bring in the patients favored foods. • Limit visitors at mealtimes so that the patient is not distracted. • Avoid offering food unless the patient initiates. • Provide thorough oral care immediately after the patient eats.

Ans: A Feedback: Family involvement and home-cooked favorite foods may help the patient to eat. Having visitors at mealtimes may make eating more pleasant and increase the patients appetite. The nurse should not place the complete onus for initiating meals on the patient. Oral care after meals is necessary, but does not influence appetite.

A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? • The patients swallowing ability • The patients ability to speak • The patients management of secretions • The patients airway patency

Ans: A Feedback: If the superior laryngeal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only affects management of secretions and airway patency indirectly.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? • The patient will require an upper endoscopy every 6 months to detect malignant changes. • Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. • Small amounts of blood are likely to be present in the stools and are not cause for concern. • Antacids may be discontinued when symptoms of heartburn subside.

Ans: A Feedback: In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? A. Ensure that none of the patients visitors has an infection. B. Arrange for a diet that is high in protein and low in fat. C. Administer colony stimulating factors (CSFs) as ordered. D. Prepare to administer chemotherapeutics as ordered.

Ans: A Feedback: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.

A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? A. Metoclopramide (Reglan) B. Omeprazole (Prilosec) C. Lansoprazole (Prevacid) D. Famotidine (Pepcid)

Ans: A Feedback: Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprozole are proton pump inhibitors that reduce gastric acid secretion. Famotidine (Pepcid) is an H2receptor antagonist, which has a similar effect.

An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? • Palpate the patients parotid glands to detect swelling and tenderness. • Assess the temporomandibular joint for evidence of a malocclusion. • Test the integrity of cranial nerve XII by asking the patient to protrude the tongue. • Inspect the patients gums for bleeding and hyperpigmentation.

Ans: A Feedback: Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? • A 65-year-old man with alcoholism who smokes • A 45-year-old woman who has type 1 diabetes and who wears dentures • A 32-year-old man who is obese and uses smokeless tobacco • A 57-year-old man with GERD and dental caries

Ans: A Feedback: Oral cancers are often associated with the use of alcohol and tobacco, which when used together have a synergistic carcinogenic effect. Most cases of oral cancers occur in people over the age of 60 and a disproportionate number of cases occur in men. Diabetes, dentures, dental caries, and GERD are not risk factors for oral cancer.

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated 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

Ans: A Feedback: Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patients 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 patients 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.

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 suture line. • Position patient on the non operative side with the head of the bed down. • Assess the patients ability to perform self-suctioning. • Evaluate the patients ability to swallow saliva and clear fluids.

Ans: A Feedback: 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. Self-sectioning may be unsafe because the patient may damage the suture line. 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 patients ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patients need for suctioning.

A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients longterm needs, the nurse should prioritize interventions and referrals with what goal? • Enhancement of verbal communication • Enhancement of immune function • Maintenance of adequate social support • Maintenance of fluid balance

Ans: A Feedback: Verbal communication may be impaired by radical surgery for oral cancer. Addressing this impairment often requires a long-term commitment. Immune function, social support, and fluid balance are all necessary, but communication is a priority issue for patients recovering from this type of surgery.

A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply. A. Perforation into the mediastinum B. Development of an esophageal lesion C. Erosion into the great vessels D. Painful swallowing E. Obstruction of the esophagus

Ans: A, C, E Feedback: In the later stages of esophageal cancer, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Painful swallowing and the emergence of a lesion are early signs of esophageal cancer.

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action? A. Document the findings as being consistent with a viable graft. B. Promptly report these indications of venous congestion. C. Closely monitor the patient and reassess in 30 minutes. D. Reposition the patient to promote peripheral circulation.

Ans: B Feedback: A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom? • Burning pain on swallowing • Regurgitation of undigested food • Symptoms mimicking a heart attack • Chronic parotid abscesses

Ans: B Feedback: An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the patient assumes a recumbent position. The patient may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum.

A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what? • Presence of small blood clots in the drainage • 60 mL of milky or cloudy drainage • Spots of drainage on the dressings surrounding the drain • 120 mL of serosanguinous drainage

Ans: B Feedback: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt treatment.

The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? • Dull pain radiating to the ears and teeth • Presence of a painless sore with raised edges • Areas of tenderness that make chewing difficult • Diffuse inflammation of the buccal mucosa

Ans: B Feedback: Malignant lesions of the oral cavity are most often painless lumps or sores with raised borders. Because they do not bother the patient, delay in seeking treatment occurs frequently, and negatively affects prognosis. Dull pain radiating to the ears and teeth is characteristic of malocclusion. Inflammation of the buccal mucosa causes discomfort and often occurs as a side effect of chemotherapy. Tenderness resulting in pain on chewing may be associated with gingivitis, abscess, irritation from dentures, and other causes. Pain related to oral cancer is a late symptom.

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? • Pyloric sphincter • Lower esophageal sphincter • Hypopharyngeal sphincter • Upper esophageal sphincter

Ans: B Feedback: The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.

A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions? • Rinse the mouth with alcohol before bedtime for the next 7 days. • Use warm saline to rinse the mouth as needed. • Brush around the area with a firm toothbrush to prevent infection. • Use a toothpick to dislodge any debris that gets lodged in the socket.

Ans: B Feedback: The patient should be assessed for bleeding after the tooth is extracted. The mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or toothpick could injure the tissues around the extracted area. Alcohol would injure tissues that are healing.

A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? • Increasing calcium intake to promote bone healing • Avoiding chewing food for the specified number of weeks after surgery • Techniques for managing parenteral nutrition in the home setting • Techniques for managing a gastrostomy

Ans: B Feedback: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary.

Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? • Eating several small meals daily rather than 3 larger meals • Keeping the head of the bed slightly elevated • Drinking carbonated mineral water rather than soft drinks • Avoiding food or fluid intake after 6:00 p.m.

Ans: B Feedback: The patient with GERD is encouraged to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks. Frequent meals are not specifically encouraged and the patient should avoid food and fluid within 2 hours of bedtime. All carbonated beverages should be avoided.

A patient 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 patient is alert. What is the patients priority need at this time? • Emotional support from visitors and staff • An effective means of communicating with the nurse • Referral to a speech therapist • Dietary teaching focused on consistency of food and frequency of feedings

Ans: B Feedback: Verbal communication may be impaired by radical surgery for oral cancer. It is therefore vital to assess the patients ability to communicate in writing before surgery. Emotional support and dietary teaching are critical aspects of the plan of care; however, the patients ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the patients rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A. Keep the head of the bed lowered. B. Drink a cup of hot tea before bedtime. C. Avoid carbonated drinks. D. Eat a low-protein diet.

Ans: C Feedback: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.

A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care? • Teaching the patient to self-suction • Performing chest physiotherapy to promote oxygenation • Positioning the patient to prevent gastric reflux • Providing a regular diet as tolerated

Ans: C Feedback: After recovering from the effects of anesthesia, the patient is placed in a low Fowlers position, and later in a Fowlers position, to help prevent reflux of gastric secretions. The patient is observed carefully for regurgitation and dyspnea because a common postoperative complication is aspiration pneumonia. In this period of recovery, self-suctioning is also not likely realistic or safe. Chest physiotherapy is contraindicated because of the risk of aspiration. Nutrition is prioritized, but a regular diet is contraindicated in the immediate recovery from esophageal surgery.

A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? • Placing the patient in a left lateral position • Administering opioids as ordered • Placing the patient in Fowlers position • Teaching the patient to use the patient-controlled analgesia (PCA) system

Ans: C Feedback: After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in Fowlers position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing.

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? • A patient who is receiving intravenous antibiotic therapy in the home setting • A patient who has a chronic venous ulcer • An older adult whose medication regimen includes an anticholinergic • A patient with poorly controlled diabetes who receives weekly wound care

Ans: C Feedback: Elderly, acutely ill, or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis. Anticholinergic medications inhibit saliva production. Antibiotics, diabetes, and wounds are not risk factors for parotitis.

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A. Assess ability to clear oral secretions. B. Assess for signs of infection. C. Assess for a patent airway. D. Assess for ability to communicate.

Ans: C Feedback: Postoperatively, the nurse assesses for a patent airway. The patients ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.

A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? • Presence of acute pain and anxiety • Tissue integrity and color of the operative site • Respiratory status and airway clearance • Self-esteem and body image

Ans: C Feedback: Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. The other assessments are part of the plan of care for a patient who has had a radical neck dissection, but are not the nurses chief priority.

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? • Muscle training to relieve dysphagia • Relieving nerve paralysis in the cervical plexus • Promoting maximum shoulder function • Alleviating achalasia by decreasing esophageal peristalsis

Ans: C Feedback: Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the patients neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist.

A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education? • Resumption of activities of daily living • Pain control • Promotion of adequate nutrition • Strategies for promoting communication

Ans: C Feedback: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the patients nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery.

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? • Promotion of a nutrient-dense, low-fat diet • Annual screening endoscopy for patients over 50 with a family history of esophageal cancer • Early diagnosis and treatment of gastroesophageal reflux disease • Adequate fluid intake and avoidance of spicy foods

Ans: C Feedback: There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history.

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? • Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash • Applying a water-soluble gel to the teeth and gums • Wiping the teeth and gums clean with a gauze pad • Brushing the patients teeth with a toothbrush and small amount of toothpaste

Ans: D Feedback: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.

A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? a. Ineffective Tissue Perfusion b. Impaired Skin Integrity c. Aspiration d. Imbalanced Nutrition: Less Than Body Requirements

Ans: D Feedback: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A. Radiation therapy often results in secondary brain tumors. B. Surgical complications are exceedingly common. C. Diagnosis rarely occurs until the cancer is endstage. D. Metastases are common and respond poorly to treatment.

Ans: D Feedback: Deaths from malignancies of the head and neck are primarily attributable to local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by way of the lymphatics before the primary lesion has been treated. This local-regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. This high mortality rate is not related to surgical complications, late diagnosis, or the development of brain tumors.

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? • Haloperidol • Prostigmine • Epinephrine • Glucagon

Ans: D Feedback: Glucagon is administered prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for patients with myastheniagravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm.

A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A. Risk for Disuse Syndrome B. Unilateral Neglect C. Risk for Trauma D. Ineffective Tissue Perfusion

Ans: D Feedback: Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.

A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery? • Assessing function of cranial nerves V, VI, and IX • Assessing for a history of GERD • Assessing for signs or symptoms of atherosclerosis • Assessing the patency of the ulnar artery

Ans: D Feedback: If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The success of this surgery is not primarily dependent on CN function or the absence of GERD and atherosclerosis.

A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action? • Encourage the patient to perform deep breathing and coughing exercises hourly. • Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula. • Activate the emergency response system. • Report this finding promptly to the physician and remain with the patient.

Ans: D Feedback: In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? • Drinking beverages after your meal, rather than with your meal, may bring some relief. • Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow. • Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating. • Instead of eating three meals a day, try eating smaller amounts more often.

Ans: D Feedback: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.

A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries? • Hormonal changes brought on by the stress response cause an acidic oral environment • Systemic infections frequently migrate to the teeth • Hydration that is received intravenously lacks fluoride • Inadequate nutrition and decreased saliva production can cause cavities

Ans: D Feedback: Many ill patients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the patient is not significant in the development of dental caries in the ill patient.