Hinkle CH 39
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. A canker sore of the oral soft tissues b. An acute stomach infection c. Acid indigestion d. An early sign of peptic ulcer disease
a. A canker sore of the oral soft tissues Explanation: Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
The nurse is caring for a client recovering from open reduction, internal fixation (ORIF) of the mandible. Which teachings will the nurse provide to the client after the surgery? Select all that apply. a. Abstain from smoking b. Refrain from ingesting alcohol c. Use medicated oral rinses as prescribed d. Follow a liquid or soft diet for 4 to 6 weeks e. Clear fluids only for the first three days
a. Abstain from smoking b. Refrain from ingesting alcohol c. Use medicated oral rinses as prescribed d. Follow a liquid or soft diet for 4 to 6 weeks Explanation: Open reduction, internal fixation (ORIF) with plate fixation (insertion of one or more metal plates and screws or arch bars into the bone to approximate and stabilize the bone) is the surgery of choice for a mandibular fracture. After the surgery, the client should be instructed to abstain from smoking and refrain from ingesting alcohol. The client should use medicated oral rinses as prescribed and follow a liquid or soft diet for 4 to 6 weeks. Oral intake is restricted to a soft diet for 7 to 10 days for maxillomandibular fixation.
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? a. Achalasia b. Diffuse spasm c. Gastroesophageal reflex disease d. Hiatal hernia
a. Achalasia Explanation: Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.
While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply. a. Administer medication for report of pain. b. Insert an intravenous (IV) catheter for administration of IV fluids. c. Maintain nothing by mouth status. d. Induce vomiting to remove the base solution from the stomach. e. Assess respiratory status every 4 hours and prn.
a. Administer medication for report of pain. b. Insert an intravenous (IV) catheter for administration of IV fluids. c. Maintain nothing by mouth status. e. Assess respiratory status every 4 hours and prn. Explanation: The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.
The nurse is caring for a client receiving a tube feeding. Which assessments will the nurse prioritize for this client? Select all that apply. a. Body weight b. Blood glucose level c. Signs of dehydration d. Placement of the tube e. Neurological assessment
a. Body weight b. Blood glucose level c. Signs of dehydration d. Placement of the tube Explanation: The nurse should assess the client receiving a tube feeding. Assessments that should be a priority include the client's body weight, the blood glucose level, signs of dehydration, and placement of the tube. The neurological assessment is not directly associated with tube feeding procedure.
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? a. Buccal mucosa next to the upper molars b. Dorsum of the tongue c. Roof of the mouth next to the incisors d. Posterior segment of the tongue near the uvula
a. Buccal mucosa next to the upper molars Explanation: The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.
The primary source of microorganisms for catheter-related infections are the skin and which of the following? a. Catheter hub b. Catheter tubing c. IV fluid bag d. IV tubing
a. Catheter hub Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply): a. Compares exposed tube length with original measurement b. Visually assesses the color of the aspirate c. Checks the pH of the gastric contents d. Confirms the tip of the tube with radiology e. Inserts 30 mL of tap water through the nasogastric tube
a. Compares exposed tube length with original measurement b. Visually assesses the color of the aspirate c. Checks the pH of the gastric contents Explanation: The nasogastric tube must be checked every shift for placement when a client is receiving continuous feedings. Recommended methods are comparing the exposed nasogastric tube length to the original measurement, visually assessing the color of the aspirate, and checking the pH of the gastric contents with a pH sensor. Confirming tube placement with radiology is costly and may be performed at the time of initial insertion. Inserting tap water through the nasogastric tube does not verify placement.
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? a. Confirm placement of the tube prior to each medication administration. b. Have the client sip cool water to stimulate saliva production. c. Keep the client in a low Fowler position when at rest. d. Connect the tube to continuous wall suction when not in use.
a. Confirm placement of the tube prior to each medication administration. Explanation: Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a NG tube the client should be positioned in a Fowler's position. Oral fluid administration is contraindicated by the client's dysphagia.
Which is the primary symptom of achalasia? a. Difficulty swallowing b. Chest pain c. Heartburn d. Pulmonary symptoms
a. Difficulty swallowing Explanation: The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? a. Dysphagia (difficulty swallowing) b. Malnutrition c. Pain d. Regurgitation of food
a. Dysphagia Explanation: Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).
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? a. Excess fluid volume b. Risk for imbalanced nutrition, more than body requirements c. Deficient fluid volume d. Impaired urinary elimination
a. Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.
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? a. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. b. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. c. Feedings can be administered with the patient in the recumbent position. d. The patient cannot experience the deprivational stress of not swallowing.
a. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.
The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician? a. High epigastric pain and/or discomfort b. Crackles that clear after coughing c. Serous drainage on the dressing d. Temperature of 99.0°F (37.2°C)
a. High epigastric pain and/or discomfort Explanation: The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? a. Increasing difficulty in swallowing b. Sensation of a mass in throat c. Foul breath d. Hiccups
a. Increasing difficulty in swallowing Explanation: The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? a. Instruct the client to swish prescribed nystatin solution for 1 minute. b. Remove the plaque from the mouth by rubbing with gauze. c. Provide saline rinses prior to meals. d. Encourage the client to ingest a soft or bland diet.
a. Instruct the client to swish prescribed nystatin solution for 1 minute. Explanation: A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.
A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort? a. Keeping the head of the bed elevated. b. Positioning the client flat on the abdomen or side. c. Providing a tracheostomy tray near the bed. d. Turning the client's head to the side.
a. Keeping the head of the bed elevated. Explanation: It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. a. Lansoprazole (Prevacid) b. Rabeprazole (AcipHex) c. Esomeprazole (Nexium) d. Famotidine (Pepcid) e. Nizatidine (Axid)
a. Lansoprazole (Prevacid) b. Rabeprazole (AcipHex) c. Esomeprazole (Nexium)
Which of the following are functions of saliva? Select all that apply. a. Lubrication b. Protection against harmful bacteria c. Digestion d. Elimination e. Metabolism
a. Lubrication b. Protection against harmful bacteria c. Digestion Explanation: The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: a. Make a notation on the call light system that the client cannot speak. b. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. c. Provide oxygen without humidity through the tracheostomy tube. d. Encourage the client to position himself on his side.
a. Make a notation on the call light system that the client cannot speak. Explanation: The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? a. Metoclopramide (Reglan) b. Famotidine (Pepcid) c. Nizatidine (Axid) d. Esomeprazole (Nexium)
a. Metoclopramide (Reglan) Explanation: Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.
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? a. No land line; cell phone available and taken by family member during working hours b. Water of low pressure that can be obtained through all faucets c. Little food in the working refrigerator d. Electricity that loses power, usually for short duration, during storms
a. No land line; cell phone available and taken by family member during working hours Explanation: A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.
The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply. a. Oral hygiene b. Follow-up dental appointment c. Follow-up medical appointment d. Use of humidification
a. Oral hygiene b. Follow-up dental appointment c. Follow-up medical appointment d. Use of humidification Explanation: Discharge teaching for a client after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? a. Place the client in the Fowler's position. b. Administer morphine for report of pain. c. Provide feeding through the gastrostomy tube. d. Empty the Jackson-Pratt device (portable drainage device).
a. Place the client in the Fowler's position. Explanation: All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.
A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care? a. Risk for Aspiration Related to Inhalation of Gastric Contents b. Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption c. Risk for Decreased Cardiac Output Related to Vasovagal Response d. Risk for Impaired Verbal Communication Related to Oral Trauma
a. Risk for Aspiration Related to Inhalation of Gastric Contents Explanation: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the client's nutritional status and does not affect cardiac output or communication.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? a. Sialolithiasis b. Parotitis c. Sialadenitis d. Stomatitis
a. Sialolithiasis Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.
A client with an esophageal structure 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? a. Hold his breath b. Take long, slow breaths c. Bear down as if having a bowel movement d. Pant like a dog
b. Take long, slow breaths Explanation: During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.
The nurse reviews data collected during a client assessment. Which lifestyle modifications will the nurse discuss with the client to prevent the development of gastroesophageal reflux disease (GERD)? Select all that apply. a. Smoking cessation b. Limit the intake of alcohol c. Avoid eating before bedtime d. Engage in intermittent fasting e. Achieve a BMI of 22
a. Smoking cessation b. Limit the intake of alcohol c. Avoid eating before bedtime e. Achieve a BMI of 22 Explanation: For clients with GERD, management begins with teaching the client to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. Lifestyle modifications include smoking cessation, limiting the intake of alcohol, avoid eating before bedtime, and weight loss. Intermittent fasting is not identified as a lifestyle modification to prevent the development of GERD.
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location? a. Tip of patient's nose b. Tragus of the ear c. Base of the neck d. Tip of the xiphoid process
a. Tip of patient's nose Explanation: To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process.
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.) a. Until bowel sound is present b. Until flatus is passed c. Until peristalsis is resumed d. Until the patient stops vomiting e. Until the tube comes out on its own
a. Until bowel sound is present b. Until flatus is passed c. Until peristalsis is resumed Explanation: Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery? a. Vagus b. Hypoglossal c. Vestibulocochlear d. Trigeminal
a. Vagus Explanation: Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.
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? a. diaphoresis, vomiting, and diarrhea. b. manifestations of electrolyte disturbances. c. manifestations of hypoglycemia. d. constipation, dehydration, and hypercapnia.
a. diaphoresis, vomiting, and diarrhea. Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route? a. nasogastric intubation b. orogastric intubation c. nasoenteric intubation d. gastrostomy
a. nasogastric intubation Explanation: The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.
The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of a. organic fruit juice. b. roasted nuts. c. red meat that is high in fat. d. cheddar cheese.
a. organic fruit juice. Explanation: Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Clients 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.
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every a. shift. b. hour. c. 12 hours. d. 24 hours.
a. shift. Explanation: Each nurse caring for the client is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the client is extremely restless or there is basis for rechecking the tube due to other client activities. Checking for placement every 12 or 24 hours does not meet the standard of care for the client receiving continuous tube feedings.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? a. "Lie down after meals to promote digestion." b. "Avoid coffee and alcoholic beverages." c. "Take antacids with meals." d. "Limit fluid intake with meals."
b. "Avoid coffee and alcoholic beverages." Explanation: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement? a. "I need to keep my head turned directly toward you and the health care provider." b. "I will be lying on my back but my legs will be higher than my head." c. "I will need to take long, slow, deep breaths when the catheter is inserted." d. "I'll have to wear a thick, bulky dressing over the site."
b. "I will be lying on my back but my legs will be higher than my head." Explanation: For catheter insertion, the client is in the Trendelenburg position to produce dilation of the neck and shoulder vessels, which makes entry easier and decreases the risk of air embolus. The client is instructed to turn the head away from the site of the venipuncture and to remain motionless while the catheter is inserted and the site is dressed. During insertion, until the syringe is detached from the needle and the catheter is inserted, the client may be asked to perform the Valsalva maneuver, not take long, slow, deep breaths. Typically a transparent dressing is applied over the insertion site.
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? a. 30 minutes b. 1 hour c. 90 minutes d. 2 hours
b. 1 hour Explanation: The semi-Fowler position is necessary for a nasogastric (NG) feeding, with the client's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? a. 4 p.m. to 6 p.m. b. 6 p.m. to 8 p.m. c. 8 p.m. to 10 p.m. d. 10 p.m. to 12 a.m.
b. 6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse a. Immediately starts the prescribed tube feeding b. Administers an initial bolus of 50 mL water c. Maintains a gauze dressing over the site for 3 days d. Pushes the stabilizing disk firmly against the skin
b. Administers an initial bolus of 50 mL water Explanation: The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown.
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? a. Emotional support from visitors and staff b. An effective means of communicating with the nurse c. Referral to a speech therapist d. Dietary teaching focused on consistency of food and frequency of feedings
b. An effective means of communicating with the nurse Explanation: Verbal communication may be impaired by radical surgery for oral cancer. Emotional support and dietary teaching are critical aspects of the plan of care; however, the client's ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the client's 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 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? a. Between 40 and 80 mL b. Approximately 80 to 120 mL c. Between 120 and 160 mL d. Greater than 160 mL
b. Approximately 80 to 120 mL Explanation: Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.
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? a. Between 40 and 80 mL b. Approximately 80 to 120 mL c. Between 120 and 160 mL d. Greater than 160 mL
b. Approximately 80 to 120 mL Explanation: Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.
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? a. Reinforce the neck dressing when blood is present on the dressing. b. Assess the graft for color and temperature. c. Administer prescribed intravenous vancomycin at the correct time. d. Cleanse around the drain using aseptic technique.
b. Assess the graft for color and temperature. Explanation: Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a. Apply water-based lubricant to the nares daily. b. Auscultate lung sounds every 4 hours. c. Inspect the nose daily for skin irritation. d. Change the nasal tape every 2 to 3 days.
b. Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.
Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. a. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. b. Avoid beer, especially in the evening. c. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. d. Elevate the head of the bed on 6- to 8-inch blocks. e. Elevate the upper body on pillows.
b. Avoid beer, especially in the evening. d. Elevate the head of the bed on 6- to 8-inch blocks. e. Elevate the upper body on pillows. Explanation: Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? a. Consume foods containing peppermint or spearmint. b. Avoid eating or drinking 2 hours before bedtime. c. Elevate the foot of the bed on 6- to 8-inch blocks. d. Eat a low-carbohydrate diet.
b. Avoid eating or drinking 2 hours before bedtime. Explanation: The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head of the bed on 6- to 8-inch blocks.
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? a. Dextrose and water b. Baking soda and water c. Full-strength peroxide d. Mouthwash and water
b. Baking soda and water Explanation: When a client is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.
When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention? a. Place the client in a supine position. b. Elevate the head of the bed 90 degrees during meals. c. Encourage the client to remove dentures. d. Encourage thin liquids for dietary intake.
b. Elevate the head of the bed 90 degrees during meals. Explanation: The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.
A client's enteral feedings have been determined to be too concentrated based on the client's development of dumping syndrome. What physiologic phenomenon caused this client's complication of enteral feeding? a. Increased gastric secretion of HCl and gastrin because of high osmolality of feeds b. Entry of large amounts of water into the small intestine because of osmotic pressure c. Mucosal irritation of the stomach and small intestine by the high concentration of the feed d. Acid-base imbalance resulting from the high volume of solutes in the feed
b. Entry of large amounts of water into the small intestine because of osmotic pressure Explanation: When a concentrated solution of high osmolality entering the intestines is taken in quickly or in large amounts, water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. This results in dumping syndrome. Dumping syndrome is not the result of changes in HCl or gastrin levels. It is not caused by an acid-base imbalance or direct irritation of the GI mucosa.
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? a. A cardiac dysrhythmia b. Fluid volume deficit c. Mucous membrane irritation d. Pulmonary complications
b. Fluid volume deficit Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.
Postoperatively, a client with a radical neck dissection should be placed in which position? a. Supine b. Fowler c. Prone d. Side-lying
b. Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.
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? a. Jejunostomy tube b. Gastrostomy tube c. Nasogastric tube d. Orogastric tube
b. Gastrostomy tube Explanation: A gastrostomy tube enters the stomach through a surgically created opening into the abdominal wall. A jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall. A nasogastric tube passes through the nose into the stomach via the esophagus. An orogastric tube passes through the mouth into the stomach.
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? a. Candidiasis b. Gingivitis c. Herpes simplex d. Cancer of the oral mucosa
b. Gingivitis Explanation: Gingivitis is a gum disease that results in painful, inflamed, swollen gums that bleed in response to light contact.
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? a. Slow the current infusion rate so that it will last until the new solution arrives. b. Hang a solution of dextrose 10% and water until the new solution is available. c. Have someone go to the pharmacy to obtain the new solution. d. Begin an infusion of normal saline in another site to maintain hydration.
b. Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.
The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse? a. Request a new bag from the pharmacy department. b. Infuse a solution containing 10% dextrose and water. c. Flush the line with 10 mL of sterile saline. d. Catch up with the next bag when it arrives.
b. Infuse a solution containing 10% dextrose and water. Explanation: If the parenteral nutrition solution runs out, a solution of 10% dextrose and water is infused to prevent hypoglycemia. The nurse would then order the next parenteral nutrition bag from the pharmacy. Flushing a peripherally inserted catheter is usually prescribed every 8 hours or per hospital established protocols. It is not the most important activity at this moment. The infusion rate should not be increased to compensate for fluids that were not infused, because hyperglycemia and hyperosmolar diuresis could occur.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? a. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. b. Keep the vent lumen above the patient's waist to prevent gastric content reflux. c. Irrigate only through the vent lumen. d. Tape the tube to the head of the bed to avoid dislodgement.
b. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse? a. Reinsert the nasogastric tube to the stomach. b. Notify the surgeon about the tube's removal. c. Place the nasogastric tube to the level of the esophagus. d. Document the discontinuation of the nasogastric tube.
b. Notify the surgeon about the tube's removal. Explanation: If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the health care provider. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the health care provider who will make a determination of leaving out or inserting a new nasogastric tube.
The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding? a. Parotitis b. Sialadenitis c. Stomatitis d. Pyosis
b. Sialadenitis Explanation: Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred? a. The nurse has inserted a tube that is too large for the patient. b. The nurse has inadvertently inserted the tube into the trachea. c. This is a normal occurrence and the tube should be left in place. d. The tube is most likely defective and should be immediately removed.
b. The nurse has inadvertently inserted the tube into the trachea. Explanation: To ensure patient safety, it is essential to confirm that the tube has been placed correctly. The tube tip may be in the esophagus, stomach, or small intestine, or inadvertently inserted in the lungs, most commonly in the right main bronchus. Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion.
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? a. Administer antibiotics via the tube as prescribed. b. Wash the area around the tube with soap and water daily. c. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. d. Irrigate the skin surrounding the insertion site with normal saline before each use.
b. Wash the area around the tube with soap and water daily. Explanation: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not given to prevent site infection.
The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention a. Change the transparent dressing every 3 days. b. Wear a face mask during dressing changes. c. Assess the PICC insertion site daily. d. Use clean gloves when providing site care.
b. Wear a face mask during dressing changes. Explanation: The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.
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? a. Spray the oropharynx with an anesthetic spray. b. Have the patient maintain a backward tilt head position. c. Allow the patient to sip water as the tube is being inserted. d. Have the patient eat a cracker as the tube is being inserted.
c. Allow the patient to sip water as the tube is being inserted. Explanation: During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.
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? a. Measure abdominal girth. b. Auscultate bowel sounds. c. Assess patency of the NG tube. d. Assess vital signs.
c. Assess patency of the NG tube. Explanation: When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but she should check NG tube patency first to help relieve the client's discomfort.
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? a. Stops the admixture while the fat emulsion infuses b. Starts a peripheral IV site to administer the fat emulsion c. Attaches the fat emulsion tubing to a Y connector close to the infusion site d. Connects the tubing for the fat emulsion above the 1.5 micron filter
c. Attaches the fat emulsion tubing to a Y connector close to the infusion site Explanation: An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.
The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition? a. Halitosis b. Zenker diverticulum c. Boerhaave syndrome d. Periapical abscess
c. Boerhaave syndrome Explanation: Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? a. Lichen planus b. Actinic cheilitis c. Chancre d. Leukoplakia
c. Chancre Explanation: A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? a. Call the physician. b. Apply a dry sterile dressing to the site. c. Clamp the catheter. d. Tell the client to take and hold a deep breath.
c. Clamp the catheter. Explanation: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.
A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct? a. Use clean technique when accessing the port with a needle. b. If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. c. Clean the port with an alcohol pad before administering I.V. fluid through the catheter. d. If unsuccessful with the first attempt to access the catheter, reuse the needle and try again.
c. Clean the port with an alcohol pad before administering I.V. fluid through the catheter. Explanation: The nurse should clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or reusing a needle would break sterile technique.
Prior to a client's scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? a. Determining the client's nutritional needs b. Determining that the client fully understands the postoperative care required c. Determining the client's ability to understand and cooperate with the procedure d. Determining the client's ability to cope with an altered body image
c. Determining the client's ability to understand and cooperate with the procedure Explanation: The major focus of the preoperative assessment is to determine the client's ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.
A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? a. Diverticulosis b. Paralytic ileus c. Dumping syndrome d. Small bowel obstruction
c. Dumping syndrome Explanation: Osmolality is an important consideration for clients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The client may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, which indicates dumping syndrome. The client's symptoms are not caused by a diverticulosis, paralytic ileus, or a small bowel obstruction.
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? a. Peptic ulcer disease b. Esophageal cancer c. Gastroesophageal reflux disease d. Diverticulitis
c. Gastroesophageal reflux disease Explanation: Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.
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 a. Coiling in the client's mouth b. Irritating the epiglottis c. Inserted into the lungs d. Passing into the esophagus
c. Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nasogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.
A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is most appropriate? a. Stop the tube feed and aspirate stomach contents. b. Increase the hourly feed rate so it finishes earlier. c. Keep the client in semi-Fowler position for 1 hour after feedings d. Administer fluid replacement by IV.
c. Keep the client in semi-Fowler position for 1 hour after feedings Explanation: To minimize dumping syndrome, the client should remain in semi-Fowler position for 1 hour after the feeding. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? a. Helping the client cope with body image changes b. Ensuring adequate nutrition c. Maintaining a patent airway d. Preventing injury
c. Maintaining a patent airway Explanation: Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.
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? a. Document the presence of stridor b. Administer a breathing treatment c. Notify the physician d. Lower the head of the bed
c. Notify the physician Explanation: The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.
A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is: a. H2-receptor antagonists. b. Antispasmodics c. Proton pump inhibitors. d. Antacids
c. Proton pump inhibitors. Explanation: Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.
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? a. Urge the client to regularly rinse the mouth with tap water. b. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. c. Provide the client with an irrigating solution of baking soda and warm water. d. Regularly wipe the outside of the client's mouth to prevent germs from entering.
c. Provide the client with an irrigating solution of baking soda and warm water. Explanation: If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.
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? a. Methicillin-resistant Streptococcus aureus (MRSA) b. Pneumococcus c. Staphylococcus aureus d. Streptococcus viridans
c. Staphylococcus aureus Explanation: People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).
An older client is diagnosed with parotitis. What bacterial infection does the nurse suspect caused the client's parotitis? a. Pseudomonas b. Pneumococcus c. Staphylococcus aureus d. Streptococcus viridans
c. Staphylococcus aureus Explanation: The elderly and debilitated clients experience decreased salivary flow from general dehydration or medications. The bacterial infection is usually caused by Staphylococcus aureus. The infecting organism travels from the mouth through the salivary gland. Pseudomonas, pneumococcus, and streptococcus are less likely to specifically affect the elderly or debilitated clients.
Select the assessment finding that the nurse should immediately report, post radical neck dissection. a. Temperature of 99°F b. Pain c. Stridor d. Localized wound tenderness
c. Stridor Explanation: Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? a. Anxiety or irritability b. Hyperactivity c. Uncontrolled rhythmic movements of the face or limbs d. Dry mouth not relieved by sugar-free hard candy
c. Uncontrolled rhythmic movements of the face or limbs Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.
The most common symptom of esophageal disease is a. nausea. b. vomiting. c. dysphagia. d. odynophagia.
c. dysphagia. Explanation: This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.
The most significant complication related to continuous tube feedings is a. the interruption of GI integrity. b. a disturbance of intestinal and hepatic metabolism. c. the increased potential for aspiration. d. an interruption in fat metabolism and lipoprotein synthesis.
c. the increased potential for aspiration. Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.
A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician? a. 150 mL b. 175 mL c. 200 mL d. 225 mL
d. 225 mL Explanation: If a residual volume greater than 200 mL is obtained twice, the nurse would need to notify the physician. A single residual volume of 200 mL or more does not indicate a need to withhold a feeding. Feedings may be continued in patients as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient's physical status.
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? a. 5-mL b. 10-mL c. 20-mL d. 30-mL
d. 30-mL Explanation: When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.
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? a. 1 b. 2 c. 4 d. 6
d. 6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.
The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? a. History of diverticulitis b. Treatment for internal hemorrhoids c. Polyps removed during a colonoscopy d. Diagnosed with malabsorption syndrome
d. Diagnosed with malabsorption syndrome Explanation: Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.
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? a. Hiatal hernia b. Gastroesophageal reflux disease c. Gastritis d. Esophageal tumor
d. Esophageal tumor Explanation: Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.
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? a. Assess the client's appetite. b. Assist the client into a supine position. c. Apply topical anesthetic to the client's nares as prescribed. d. Explain the process clearly to the client.
d. Explain the process clearly to the client. Explanation: The process should be explained to the client before removal. A client should not normally be supine with an NG tube in place and anesthetic is not normally prescribed. Removal is not contingent on the client's appetite.
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? a. Remove the tape from the nose of the client. b. Withdraw the tube gently for 6 to 8 inches. c. Provide oral hygiene. d. Flush with 10 mL of water.
d. Flush with 10 mL of water. Explanation: Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.
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? a. Ineffective Tissue Perfusion b. Impaired Skin Integrity c. Aspiration d. Imbalanced Nutrition: Less Than Body Requirements
d. Imbalanced Nutrition: Less Than Body Requirements Explanation: 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 person's nutritional status. Dental caries do not typically affect the client's tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as a. Impaired tissue integrity related to surgical intervention b. Imbalanced nutrition: less than body requirements, related to treatment c. Risk for infection related to surgical intervention d. Ineffective airway clearance related to obstruction by mucus
d. Ineffective airway clearance related to obstruction by mucus Explanation: All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.
The client has a chancre on the lips. What instruction should the nurse provide? a. Apply warm soaks to the lip. b. Gargle with an antiseptic solution. c. Avoid foods that could irritate the lesion. d. Take measures to prevent spreading the lesion to other people.
d. Take measures to prevent spreading the lesion to other people. Explanation: A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? a. Serosanguineous drainage on the dressing b. Foley catheter bag containing 500 ml of amber urine c. A piggyback infusion of levofloxacin d. The client lying in a lateral position, with the head of bed flat
d. The client lying in a lateral position, with the head of bed flat Explanation: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? a. Abdominal distention, elevated temperature, weakness before eating b. Constipation, rectal bleeding following bowel movements c. Persistent loose stools, chills, hiccups after eating d. Weakness, diaphoresis, diarrhea 90 minutes after eating
d. Weakness, diaphoresis, diarrhea 90 minutes after eating Explanation: Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? a. When the residual is about 50 mL b. When the residual is between 50 and 80 mL c. When the residual is about 100 mL d. When the residual is greater than 200 mL
d. When the residual is greater than 200 mL Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.