Ch. 22: Oral & Esophagus PREPU

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?

*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.

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? a. simple compressed tablets b. buccal or sublingual tablets c. enteric-coated tablets d. soft, gelatin capsules filled with liquid

*c. enteric-coated tablets * Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for clients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for clients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the client undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

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* Symptoms may include *pyrosis* (burning sensation in the esophagus), *dyspepsia* (indigestion), regurgitation, *dysphagia* or odynophagia (pain on swallowing), hypersalivation, and esophagitis.

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.*

The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is.. a. Auscultate lung sounds. b. Position client flat in bed. c. Elevate the head of the bed. d. Consult with the healthcare provider.

*a. Auscultate lung sounds. * Following placement of a central line, the *client is at risk for a pneumothorax*. The client's report of *anxiety* and *increased respiratory rate* may be the *first signs and symptoms of a pneumothorax*. The nurse first assesses the client by auscultating lung sounds. Other actions include placing the client in Fowler's position and consulting with the healthcare provider about findings.

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* 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.

A 26-year-old man experienced severe burns in an industrial accident and has been admitted to the burn unit of a tertiary care hospital. In the days since the accident, the care team has been pleased with the trajectory of the man's recovery, and they estimate that he will require parenteral nutrition for 2 to 3 months. Which of the following access devices is most likely appropriate for this patient's nutritional needs? a. Implanted port b. Tunneled central catheter c. Peripherally inserted central catheter (PICC) d. Nontunneled central catheter

*c. Peripherally inserted central catheter (PICC) * PICCs are used for feedings of a few weeks to a few months. Implanted ports and tunneled central lines are for longer-term use, and nontunneled central catheters are used for short-term (<6 weeks) IV therapy.

The most common symptom of esophageal disease is a. nausea. b. vomiting. c. dysphagia. d. odynophagia.

*c. dysphagia* 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.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply a. Daily weights b. Intake and output monitoring c. Calorie counts for oral nutrients d. Daily transparent dressing changes e. Strict bedrest

*a. Daily weights b. Intake and output monitoring c. Calorie counts for oral nutrients* For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

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 b. Malnutrition c. Pain d. Regurgitation of food

*a. Dysphagia * 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 * 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.

A patient has been NPO for two days anticipating surgery which has been repeatedly delayed. In addition to risks of nutritional and fluid deficits, the nurse determines that this patient is at the greatest risk for: a. altered oral mucous membranes. b. physical injury. c. ineffective social interaction. d. confusion.

*a. altered oral mucous membranes.* Not drinking anything by mouth can result in drying of the oral mucous membranes, compromising their integrity. Being NPO is unrelated to physical injury or ineffective social interaction. Confusion is unlikely to result from the client's NPO status.

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid) Esomeprazole (Nexium)

*Metoclopramide (Reglan)* 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), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus and has been admitted to a medical unit. The nurse is writing a care plan for this patient. What information is essential to include? a. He will need to undergo an upper endoscopy every 6 months to detect malignant changes. b. Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage. c. Small amounts of blood are likely to be present in his stools and should not cause concern. d. Antacids may be discontinued when symptoms of heartburn subside

*a. He will need to undergo an upper endoscopy every 6 months to detect malignant changes.* In the patient with Barrett's esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. *The altered cells are considered precancerous and are a precursor to esophageal cancer.* To facilitate early detection of malignant cells, upper endoscopies may be performed every 6 to 12 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or which are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

The nurse is preparing to administer an IV fat emulsion simultaneously with parenteral nutrition (PN). What approach to the administration of a fat emulsion is appropriate? a. IV fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. b. The nurse should prepare for placement of another IV line, as IV fat emulsions may not be infused simultaneously through the line used for PN. c. IV fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. d. The IV fat emulsions can be piggy-backed into any existing IV solution that is infusing.

*a. IV fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.* IV fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The patient does not need another IV line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to: a. Instruct the client to swish prescribed nystatin (Mycostatin) 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 (Mycostatin) solution for 1 minute.* A *cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis*. The most effective treatment is anitfungal 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.

Tube feedings are advised for a client who is recovering from oral surgery. The nurse manages the tube feedings to minimize the risk of aspiration. Which measures should the nurse include in the care plan to *reduce the risk of aspiration*? Select all that apply. a. Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. b. Check tube placement and gastric residual prior to feedings. c. Administer 15 to 30 mL of water before and after medications and feedings. d. Change the tube feeding container and tubing.

*a. Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. b. Check tube placement and gastric residual prior to feedings* Proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting.

A nurse is conducting morning assessments of several medical patients and has entered the room of a patient who has a nasogastric (NG) tube in situ. Immediately, the nurse observes that the tube has become unsecured from the patient's nose and the mark at the desired point of entry is now approximately 8 inches from the patient's nose. How should the nurse best respond to this assessment finding? a. Reinsert the NG tube and arrange for x-ray confirmation of placement. b. Remove the NG tube and obtain an order for reinsertion. c. Reinsert the NG tube and monitor the patient closely for signs of aspiration. d. Reinsert the NG tube and aspirate stomach contents to confirm correct placement.

*a. Reinsert the NG tube and arrange for x-ray confirmation of placement. * If the patient's NG tube becomes unsecured, placement should be reconfirmed; the most accurate form of confirmation is an x-ray.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is: a. loose, watery stools. b. increased urination. c. elevated blood pressure. d. decreased pulse rate.

*a. loose, watery stools. * When the client indicates that loose, watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the client understands the teaching of metabolic complications. *Signs and symptoms of metabolic complications from PN* include: neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

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* The semi-Fowler position is necessary for a 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.

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? a. 6 b. 4 c. 10 d. 8

*b. 4* Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater

An older woman has been receiving enteral feeds by nasogastric (NG) tube for the past several days due to a decrease in her level of consciousness. How can the nurse best assess the patient's tolerance of the current formula and rate of delivery? a. Carefully document the number and consistency of bowel movements. b. Aspirate and measure the stomach contents on a regular basis. c. Monitor the patient's skin turgor and the color of her sclerae. d. Perform regular chest auscultation and monitor her oxygen saturation levels.

*b. Aspirate and measure the stomach contents on a regular basis. * Patient tolerance of liquid enteral nutrition is determined by residual measurement. The *volume of aspirate indicates the rate at which the patient is digesting the feedings and how quickly the chyme is passing into the small intestine*. Respiratory assessment is important because of the risk of aspiration, but doing so does not necessarily determine tolerance of the feeds. Skin turgor is not an accurate assessment in older adults. Bowel patterns are a significant assessment, but these do not necessarily indicate tolerance or a lack thereof.

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? a. Radiation b. Lithotripsy c. Chemotherapy d. Biopsy

*b. Lithotripsy* Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.

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* 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.

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 a. Hypertension b. Diarrhea c. Decreased bowel sounds d. Tachycardia e. Diaphoresis

*b. diarrhea d. tachycardia e. 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 client is on a continuous tube feeding. The nurse determines the tube placement should be checked every: a. 12 hour b. shift c. 24 hours d. 1 hour

*b. shift* 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.* 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.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? a. Dry skin b. Slowed heart beat c. Diarrhea d. Hyperglycemia

*c. diarrhea* Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces: - weakness, - dizziness, - sweating, - palpitations, - abdominal cramps, and - diarrhea, - hypotension which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

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. * 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.

*Rebound hypoglycemia* is a complication of parenteral nutrition caused by: a. glucose intolerance. b.fluid infusing rapidly. c.feedings stopped too abruptly. d. a cap missing from the port.

*c.feedings stopped too abruptly. * Rebound hypoglycemia occurs when the feedings are stopped too abruptly because body has to adjust to the ↓ amounts of glucose in the body. . Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port

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.* 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.

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* 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.