Chapter 39

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

Apply pressure to the bleeding site The first action for the nurse is to apply pressure to the bleeding site. The nurse will need to obtain assistance, elevate the head of the bed, and notify the surgeon, but client care is most important initially.

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Occult bleeding Bowel disease of unknown origin Inflammatory bowel disease Cancer

Cancer

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

Fowler

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastritis Gastroesophageal reflux disease Diverticulitis with perforation Peptic ulcer with melena

Gastroesophageal reflux disease

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? Decrease nausea and vomiting Recover from the general anesthesia Ambulate independently Increase the amount of fluids

Increase the amount of fluids

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? Regularly wipe the outside of the client's mouth to prevent germs from entering. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. Provide the client with an irrigating solution of baking soda and warm water. Urge the client to regularly rinse the mouth with tap water.

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

The nurse determines which is a true statement regarding older clients, considering the age-related effects on their GI system? They have no awareness of the filling reflex. They tend to have increased muscle tone and mass. They tend to have higher physiologic reserves to compensate for fluid loss. They tend usually to have less control of the rectal sphincter.

They tend usually to have less control of the rectal sphincter.

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? Bear down as if having a bowel movement Pant like a dog Take long, slow breaths Hold his breath

Take long, slow breaths

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer? V formation on dorsum of tongue red plaque on undersurface of tongue thin, white coating on dorsum of tongue large, vallate papillae on dorsum of tongue

red plaque on undersurface of tongue

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Avoid coffee and alcoholic beverages." "Lie down after meals to promote digestion." "Limit fluid intake with meals." "Take antacids with meals."

"Avoid coffee and alcoholic beverages."' 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.

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

Approximately 80 to 120 mL

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? Starts a peripheral IV site to administer the fat emulsion Connects the tubing for the fat emulsion above the 1.5 micron filter Stops the admixture while the fat emulsion infuses Attaches the fat emulsion tubing to a Y connector close to the infusion site

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

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Consume foods containing peppermint or spearmint. Avoid eating or drinking 2 hours before bedtime. Eat a low-carbohydrate diet. Elevate the foot of the bed on 6- to 8-inch blocks.

Avoid eating or drinking 2 hours before bedtime. 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 primary source of microorganisms for catheter-related infections are the skin and which of the following? Catheter tubing IV tubing Catheter hub IV fluid bag

Catheter hub

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? Commercial enzyme product Digestive enzyme mixed with warm water Air insufflation Cranberry juice

Cranberry juice 'To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube.

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? Gastroesophageal reflux disease Esophageal tumor Hiatal hernia Gastritis

Esophageal tumor 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.

Cancer of the esophagus is most often diagnosed by which of the following? Barium swallow X-ray Fluoroscopy Esophagogastroduodenoscopy (EGD) with biopsy and brushings

Esophagogastroduodenoscopy (EGD) with biopsy and brushings Currently, diagnosis is confirmed most often by EGD with biopsy and brushings. The biopsy can be used to determine the presence of disease and cell differentiation. X-ray, barium swallow, and fluoroscopy are used in the diagnosis of hiatal hernia.

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was: Greater than 200 mL. About 50 mL. Between 50 and 80 mL. About 100 mL.

Greater than 200 mL.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Foul breath Sensation of a mass in throat Hiccups Increasing difficulty in swallowing

Increasing difficulty in swallowing

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? Instruct the client to swish prescribed nystatin solution for 1 minute. Provide saline rinses prior to meals. Remove the plaque from the mouth by rubbing with gauze. Encourage the client to ingest a soft or bland diet.

Instruct the client to swish prescribed nystatin solution for 1 minute.

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? Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Keep the vent lumen above the patient's waist to prevent gastric content reflux.

Keep the vent lumen above the patient's waist to prevent gastric content reflux. 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.

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Monitoring the feeding closely. Lowering the head of the bed. Increasing the feeding rate. Flushing the feeding tube.

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

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding. Discontinue the infusion. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained 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 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): Involution of the esophagus, which causes a severe stricture. Twisting of the duodenum through an opening in the diaphragm. Extension of the esophagus through an opening in the diaphragm. Protrusion of the upper stomach into the lower portion of the thorax.

Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

The client has a chancre on the lips. What instruction should the nurse provide? Take measures to prevent spreading the lesion to other people. Avoid foods that could irritate the lesion. Gargle with an antiseptic solution. Apply warm soaks to the lip.

Take measures to prevent spreading the lesion to other people.

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred? The nurse has inserted a tube that is too large for the patient. The tube is most likely defective and should be immediately removed. The nurse has inadvertently inserted the tube into the trachea. This is a normal occurrence and the tube should be left in place.

The nurse has inadvertently inserted the tube into the trachea. 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 graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action: Contaminates gloves and obtains a pair of sterile gloves for use Uses a circular motion from insertion site outward Cleanses the insertion site with a chlorhexidine solution Wipes catheter ports from distal end to insertion site

Wipes catheter ports from distal end to insertion site

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

Zenker's diverticulum

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

acidic The pH of gastric aspirate is acidic (1 to 5).

The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest? cyclic feedings continuous feedings bolus feedings intermittent feedings

continuous feedings Continuous feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, and cyclic feedings are not advised.

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? manifestations of hypoglycemia. constipation, dehydration, and hypercapnia. diaphoresis, vomiting, and diarrhea. manifestations of electrolyte disturbances.

diaphoresis, vomiting, and diarrhea. 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 nurse provides health teaching to inform the client with oral cancer that a typical lesion is soft and craterlike. many oral cancers produce no symptoms in the early stages. most oral cancers are painful at the outset. blood testing is used to diagnose oral cancer.

many oral cancers produce no symptoms in the early stages. The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.

The nurse cares for a client who receives feedings through a nasogastric (NG) tube and assesses the client for signs and symptoms of pulmonary complications. The nurse determines the client may be experiencing pulmonary complications when which sign is noted? respiratory rate of 30 temperature of 97°F pulse 88 blood pressure of 110/72

respiratory rate of 30 The nurse determines that the client may be having pulmonary complications when the respiratory rate is 30, indicating tachypnea. Other signs/symptoms of pulmonary complications include coughing during food or medication administration, difficulty clearing the airway, and fever.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Clamp the catheter. Call the physician. Apply a dry sterile dressing to the site. Tell the client to take and hold a deep breath.

Clamp the catheter. 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. pg 1245

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? Dumping syndrome Diverticulosis Small bowel obstruction Paralytic ileus

Dumping syndrome 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.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: The patient cannot experience the deprivational stress of not swallowing. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

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? Nontunneled central catheter Peripheral catheter Tunneled central catheter Implanted port

Nontunneled central catheter Because therapy will last fewer than 6 weeks, the client will most likely receive a nontunneled central catheter. A peripheral catheter should not be used for four weeks because peripheral sites must be rotated every 72 hours. A tunneled catheter and implanted ports are used for long-term therapy.

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? Notify the physician Document the presence of stridor Administer a breathing treatment Lower the head of the bed

Notify the physician 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 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? Begin an infusion of normal saline in another site to maintain hydration. Slow the current infusion rate so that it will last until the new solution arrives. Have someone go to the pharmacy to obtain the new solution. Hang a solution of dextrose 10% and water until the new solution is available.

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

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 Ineffective airway clearance related to obstruction by mucus Risk for infection related to surgical intervention Imbalanced nutrition: less than body requirements, related to treatment Impaired tissue integrity related to surgical intervention

Ineffective airway clearance related to obstruction by mucus 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.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse? Notify the surgeon about the tube's removal. Document the discontinuation of the nasogastric tube. Place the nasogastric tube to the level of the esophagus. Reinsert the nasogastric tube to the stomach.

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

Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly. The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Peptic ulcer disease Diverticulitis Gastroesophageal reflux disease Esophageal cancer

Gastroesophageal reflux disease

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse Discusses with the nutritionist about increasing the osmolality of the feeding Administers the feeding at a cooler temperature Increases the amount of feeding at the next feeding Consults with the physician about decreasing the feeding to half-strength

Consults with the physician about decreasing the feeding to half-strength The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution.

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select? Levin tube Salem sump tube Miller-Abbott tube Sengstaken-Blakemore tube

Levin tube

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client is free from esophagitis and achalasia. The client reports diminished duodenal inflammation. The client doesn't exhibit rectal tenesmus. The client has normal gastric structures.

The client is free from esophagitis and achalasia.

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

Vagus

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

Weakness, diaphoresis, diarrhea 90 minutes after eating

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? Diagnosed with malabsorption syndrome Polyps removed during a colonoscopy Treatment for internal hemorrhoids History of diverticulitis

Diagnosed with malabsorption syndrome 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.

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

Tachycardia Diarrhea Diaphoresis Dumping syndrome is manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The client often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? When the residual is about 100 mL When the residual is greater than 200 mL When the residual is about 50 mL When the residual is between 50 and 80 mL

When the residual is greater than 200 mL 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.

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. Remove the tape from the nose of the client. Provide oral hygiene. Withdraw the tube gently for 6 to 8 inches.

Flush with 10 mL of water. 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. pg 1247