Exam 2 Esophageal chapter 39. prep u

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lung sounds every 4 hours.

he 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.

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

A client is to receive parenteral nutrition for 4 weeks. What type of catheter would the nurse prepare to teach the client about the planned nutrition?

Non-tunneled central catheter

Which clinical manifestation is not associated with hemorrhage?

Bradycardia.

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 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

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed

when the residual is greater than 200ml.

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

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

Avoid coffee and alcoholic beverages."

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?

Avoid eating or drinking 2 hours before bedtime

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?

Esophageal tumor

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.?

Inserted into the lungs.

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

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

A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis

Imbalanced Nutrition: Less Than Body Requirements

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

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) 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 client's parotid glands to detect swelling and tenderness.

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)

Protrusion of the upper stomach into the lower portion of the thorax.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Diarrhae. Dumping syndrome signs are :weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum.

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

1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.

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, it is usual to have:

Asymptomatic. no symptoms

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.

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

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 client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client

Assess the graft for color and temperature

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?

Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.

A client's new onset of dysphagia has required insertion of a nasogastric (NG) tube for feeding. What intervention should the nurse include in the client's plan of care?

Confirm placement of the tube prior to each medication administration

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 and cola

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..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.

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

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

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 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."

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care

Provide frequent mouth care.

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

Sialadenitis

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 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?

Take long, slow breaths

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

The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply

Until bowel sound is present Until flatus is passed Until peristalsis is resumed.

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

Vagus

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift

which is the primary symptom of achalasia?

the primary symptom of achalasia is difficulty in swallowing both liquids and solids. chest pain or heartburns are other symptoms.