ch22: oral/esophageal
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? "It helps regulate the pressure on the suction machine." "It is a vent that prevents backflow of the secretions." "It acts as a siphon, pulling secretions into the clear tubing." "It works as a marker to make sure that the tube stays in place."
"It is a vent that prevents backflow of the secretions." The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? 2 hours 1 hour 90 minutes 30 minutes
1 hour 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.
The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient? Evaluate the patient's ability to swallow saliva and clear fluids. Avoid applying suction on or near the graft site. Position patient on his nonoperative side with the head of the bed down. Assess viability of the graft before beginning suctioning.
Avoid applying suction on or near the graft site. The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patient's ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patient's need for suctioning.
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): Confirms the tip of the tube with radiology Inserts 30 mL of tap water through the nasogastric tube Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents
Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents 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 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? Digestive enzyme mixed with warm water Commercial enzyme product 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.
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. Elevate the upper body on pillows. Avoid beer, especially in the evening. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. Elevate the head of the bed on 6- to 8-inch blocks.
Elevate the upper body on pillows. Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Hiccups Foul breath Sensation of a mass in throat Increasing difficulty in swallowing
Increasing difficulty in swallowing 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 patient with a small bowel obstruction has had a Levin tube inserted and is admitted to a medical unit. The nurse who is caring for this patient is now checking that the wall suction settings are correct and should anticipate which of the following settings? Continuous low suction Intermittent low suction Intermittent high suction Continuous high suction
Intermittent low suction If a Levin tube is used, it must be on intermittent low wall suction (30 to 40 mm Hg) to prevent gastric erosion or tearing of the stomach lining.
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? Administer a breathing treatment Document the presence of stridor Lower the head of the bed Notify the physician
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.
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? Discontinue the infusion. Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding. 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.
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? Pneumococcus Streptococcus viridans Methicillin-resistant Streptococcus aureus (MRSA) Staphylococcus aureus
Staphylococcus aureus 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).
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? Hold his breath Take long, slow breaths Bear down as if having a bowel movement Pant like a dog
Take long, slow breaths 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 is checking placement of a nasogastric (NG) tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate? The tube is in the pleural space. The tube is in the stomach. The tube is the intestine. The tube is in the esophagus.
The tube is in the stomach. The patient's aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Clear, yellow, and bile-colored are associated with intestinal aspirate. Tan mucus is associated with tracheobronchial secretions, and pleural secretions are pale yellow.
Which of the following is the most common type of diverticulum? Mid-esophageal Epiphrenic Zenker's diverticulum Intramural
Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? 30 minutes 15 minutes 60 minutes 80 minutes
30 minutes Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? 50 to 75 mL 20 to 40 mL 160 to 200 mL 80 to 120 mL
80 to 120 mL Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse Immediately starts the prescribed tube feeding Maintains a gauze dressing over the site for 3 days Pushes the stabilizing disk firmly against the skin Administers an initial bolus of 50 mL water
Administers an initial bolus of 50 mL water 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 patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Buccal Submandibular Sublingual Parotid
Parotid 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? Implanted port Nontunneled central catheter Tunneled central catheter Peripherally inserted central catheter (PICC)
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 nausea. vomiting. odynophagia. dysphagia.
dysphagia. Dysphagia 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 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? 20-mL 30-mL 5-mL 10-mL
30-mL 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 is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding at a warm temperature to decrease peristalsis. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. Administer the feeding by bolus to prevent continuous intestinal distention.
Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, not at a warm temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated), rather than by bolus, to prevent sudden distention of the intestine. Instill the minimal amount of water needed to flush the tubing before and after a feeding, not to dilute the formula but because fluid given with a feeding increases intestinal transit time.
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by Providing fluids to drink Preparing for a barium swallow Assessing lung sounds Administering the prescribed analgesic
Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.
The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? Eliminating cucumbers and other foods with seeds. Avoiding steamed foods. Eliminating spicy foods. Avoiding chocolate and coffee.
Avoiding chocolate and coffee. Chocolate, tea, cola, and caffeine lower esophageal sphincter pressure, thereby increasing reflux. Clients do not need to eliminate spicy foods unless such foods bother them. Foods with seeds are restricted in diverticulosis. Steamed foods are encouraged to retain vitamins and decrease fat intake.
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? Periapical abscess Halitosis Boerhaave syndrome Zenker diverticulum
Boerhaave syndrome 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.
Nasogastric tube feedings are advised for a client who is recovering from oral surgery. Which measure(s) should the nurse include in the care plan to reduce the risk of aspiration? Select all that apply. Place client in semi-Fowler position during and 30 to 60 minutes after an intermittent feeding. Change the tube feeding container and tubing. Check tube placement and gastric residual prior to feedings. Administer 15 to 30 mL of water before and after medications and feedings. Stop feeding if the client vomits or if aspiration is suspected.
Check tube placement and gastric residual prior to feedings. Place client in semi-Fowler position during and 30 to 60 minutes after an intermittent feeding. Stop feeding if the client vomits or if aspiration is suspected. Proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. Stopping the feeding if the client vomits prevents further problems and allows for treatment of the immediate problem. Administering 15 to 30 mL of water before and after medications and feedings, and changing the tube feeding container and tubing reduces the risk of bacterial infection and crusting or blockages of the feeding tube.
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? History of diverticulitis Diagnosed with malabsorption syndrome Treatment for internal hemorrhoids Polyps removed during a colonoscopy
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.
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Remove the tape from the nose of the client. Withdraw the tube gently for 6 to 8 inches. Provide oral hygiene. Flush with 10 mL of water.
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.
A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document? Hairy leukoplakia Erythroplakia Nicotine stomatitis Aphthous stomatitis
Hairy leukoplakia Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.
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? Small amounts of blood are likely to be present in his stools and should not cause concern. Antacids may be discontinued when symptoms of heartburn subside He will need to undergo an upper endoscopy every 6 months to detect malignant changes. Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage.
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.
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. Provide the client with an irrigating solution of baking soda and warm water. Urge the client to regularly rinse the mouth with tap water. 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. 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.
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? Reinsert the NG tube and arrange for x-ray confirmation of placement. Remove the NG tube and obtain an order for reinsertion. Reinsert the NG tube and monitor the patient closely for signs of aspiration. Reinsert the NG tube and aspirate stomach contents to confirm correct placement.
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.
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery? Trigeminal Hypoglossal Vagus Vestibulocochlear
Vagus 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.
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 Change the transparent dressing every 3 days. Assess the PICC insertion site daily. Use clean gloves when providing site care. Wear a face mask during dressing changes.
Wear a face mask during dressing changes. 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.
A patient has been NPO for two days anticipating a surgical procedure that 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: confusion. ineffective social interaction. physical injury. altered oral mucous membranes.
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.