Chapter 22: Nursing Management: Patients With Oral and Esophageal Disorders and Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition

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. A. Instruct the client to eat slowly and chew the food thoroughly. B. Inform the client to remain upright for at least 2 hours after meals. C. Encourage the client to eat frequent, small, well-balanced meals. D. Encourage the client to eat later in the day before bedtime rather than early in the morning. E. Instruct the client to avoid alcohol or tobacco products.

A. Instruct the client to eat slowly and chew the food thoroughly. B. Inform the client to remain upright for at least 2 hours after meals. C. Encourage the client to eat frequent, small, well-balanced meals. E. Instruct the client to avoid alcohol or tobacco products. 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 59-year-old woman with a recent history of heartburn, regurgitation, and occasional dysphagia has been diagnosed with a sliding hiatal hernia following an upper GI series. The nurse is providing patient education about the management of this health problem. What should the nurse suggest as a management strategy to this patient? A. Remaining upright for at least 1 hour following each meal B. Abstaining from alcohol C. Drinking one to two glasses of water before and after each meal D. Minimizing her intake of highly spiced foods and dairy products

A. Remaining upright for at least 1 hour following each meal Management for a sliding hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Fluid intake is encouraged, but this should be ingested throughout a meal, not just before and after the meal. It is not necessary to refrain from drinking alcohol, spicy foods, or dairy products.

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education? A. Surgical removal of the diverticulum B. A low-residue diet C. Chemotherapeutic agents D. Radiation therapy

A. Surgical removal of the diverticulum Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. A low-residue diet will not stop the progression of the disease. Chemotherapy and radiation therapy will not target the specific site of the Zenker's diverticulum.

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. Assess the graft for color and temperature. B. Cleanse around the drain using aseptic technique. C. Reinforce the neck dressing when blood is present on the dressing. D. Administer prescribed intravenous vancomycin at the correct time.

A. Assess the graft for color and temperature. 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 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. Calorie counts for oral nutrients C. Strict bedrest D. Daily transparent dressing changes E. Intake and output monitoring

A. Daily weights B. Calorie counts for oral nutrients E. Intake and output monitoring 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.

Which of the following are functions of saliva? Select all that apply. A. Digestion B. Lubrication C. Metabolism D. Elimination E. Protection against harmful bacteria

A. Digestion B. Lubrication E. Protection against harmful bacteria The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.

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 client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse A. Pushes the stabilizing disk firmly against the skin B. Administers an initial bolus of 50 mL water C. Immediately starts the prescribed tube feeding D. Maintains a gauze dressing over the site for 3 days

B. 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.

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. Have the patient maintain a backward tilt head position. B. Allow the patient to sip water as the tube is being inserted. C. Have the patient eat a cracker as the tube is being inserted. D. Spray the oropharynx with an anesthetic spray.

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

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. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. B. Avoid beer, especially in the evening. C. Elevate the upper body on pillows. D. Elevate the head of the bed on 6- to 8-inch blocks. E. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus.

B. Avoid beer, especially in the evening. C. Elevate the upper body on pillows. D. 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 patient diagnosed with esophageal reflux disorder has been admitted to the floor. When planning teaching for this patient what should the nurse advise the patient to do? A. Drink a cup of hot tea before bedtime. B. Avoid carbonated drinks. C. Keep the head of the bed lowered. D. Drink a carbonated drink after meals.

B. Avoid carbonated drinks. For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. A high-fiber, low-fat diet should be eaten daily.

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. Full-strength peroxide B. Baking soda and water C. Dextrose and water D. Mouthwash and water

B. Baking soda and water 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.

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. Small bowel obstruction B. Dumping syndrome C. Paralytic ileus D. Diverticulosis

B. 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.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? A. Withdraw the tube gently for 6 to 8 inches. B. Flush with 10 mL of water. C. Provide oral hygiene. D. Remove the tape from the nose of the client.

B. 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.

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

B. Fowler The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position also promotes expansion of 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 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. Have someone go to the pharmacy to obtain the new solution. B. Hang a solution of dextrose 10% and water until the new solution is available. C. Begin an infusion of normal saline in another site to maintain hydration. D. 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. 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 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. Antacids may be discontinued when symptoms of heartburn subside B. He will need to undergo an upper endoscopy every 6 months to detect malignant changes. C. Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage. D. Small amounts of blood are likely to be present in his stools and should not cause concern.

B. 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.

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

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

Total parenteral nutrition (TPN) has been ordered for a male patient who has been experiencing a severe and protracted exacerbation of Crohn's disease. Before TPN can be initiated, the patient requires: A. Angiography to determine the patency of his vascular system B. The insertion of a central venous access device C. A fluid challenge to assess his renal function D. A random blood glucose level of ≤160 mg/dL

B. The insertion of a central venous access device Because of its high osmotic pressure, TPN may only be administered through a central line. Its use does not directly depend on renal function or specific blood glucose levels. Angiography is not required before the initiation of TPN.

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: A. confusion. B. altered oral mucous membranes. C. physical injury. D. ineffective social interaction.

B. 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.

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

C. "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 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? A. "It helps regulate the pressure on the suction machine." B. "It acts as a siphon, pulling secretions into the clear tubing." C. "It is a vent that prevents backflow of the secretions." D. "It works as a marker to make sure that the tube stays in place."

C. "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.

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. 10 p.m. to 12 a.m. B. 8 p.m. to 10 p.m. C. 6 p.m. to 8 p.m. D. 4 p.m. to 6 p.m.

C. 6 p.m. to 8 p.m. 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 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? A. Elevate the head of the patient's bed B. Notify the surgeon to repair the vessel C. Apply pressure to the bleeding site D. Summon assistance

C. 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 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. Greater than 160 mL B. Between 40 and 80 mL C. Approximately 80 to 120 mL D. Between 120 and 160 mL

C. Approximately 80 to 120 mL 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.

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. Esophageal cancer B. Diverticulitis C. Gastroesophageal reflux disease D. Peptic ulcer disease

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.

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

C. Greater than 200 mL. Research demonstrates that residual volumes of less than 200 mL appear to be well tolerated without risk of aspiration.

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

C. 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 inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? A. The distance determined by measuring from the tragus of the ear to the xiphoid process B. A length of 50 cm (20 in) C. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process D. A point that equals the distance from the nose to the xiphoid process

C. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease, it is usual to have: A. mouth pain. B. oral numbness. C. no symptoms. D. oral bleeding.

C. no symptoms. The early stage of oral cancer is characteristically asymptomatic.

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the A. interruption in fat metabolism and lipoprotein synthesis. B. disturbance in the sequence of intestinal and hepatic metabolism. C. potential risk for aspiration. D. interruption of GI integrity.

C. potential risk 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.

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.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? A. Use a hard-bristled toothbrush. B. Rinse with an alcohol-based solution. C. Continue with the usual diet. D. Brush and floss daily.

D. Brush and floss daily. The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.

Which is an accurate statement regarding cancer of the esophagus? A. It is seen more frequently in European Americans than in African Americans. B. It usually occurs in the fourth decade of life. C. It is three times more common in women than men in the United States . D. Chronic irritation of the esophagus is a known risk factor.

D. Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men than in women. It is seen more frequently in African Americans than in European Americans. It usually occurs in the fifth decade of life.

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. Treatment for internal hemorrhoids B. History of diverticulitis C. Polyps removed during a colonoscopy D. Diagnosed with malabsorption syndrome

D. 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.

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries? A. Eating fruits and cheese in diet B. Drinking fluoridated water C. Using a soft-bristled toothbrush D. Exhibiting hemoglobin A1C 8.2

D. Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

A client has a 3 lumen central line inserted into the subclavian vein for parenteral nutrition. Which approach will the nurse take to maintain patency? A. Flush each port with normal saline in a 3 mL syringe once a day. B. Flush each port with normal saline in a 2-mL syringe every 12 hours. C. Flush each port with sterile water in a 2 mL syringe every 8 hours. D. Flush each port with diluted heparin in a 10 mL syringe once a shift.

D. Flush each port with diluted heparin in a 10 mL syringe once a shift. Flushing is necessary daily when the catheter is not in use. Lumens are flushed with normal saline or diluted heparin (10 U/mL) after each intermittent infusion and after blood drawing; a 10-mL syringe is to be used. Smaller volume syringes are not to be used because the pressure from smaller syringes is potentially harmful to the catheter. A 3-mL syringe with normal saline should not be used. Sterile water is not used to flush the lumens of a central line. A 2-mL syringe should not be used to flush the lumen of a central line.

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

D. 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.

The nurse caring for a patient who is being discharged home after a radical neck dissection has worked with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? A. Compensates effectively for alteration in ability to communicate related to dysarthria B. Freely expresses needs and concerns related to postoperative pain management C. Demonstrates effective stress management techniques to promote muscle relaxation D. Indicates acceptance of altered appearance and demonstrates positive self-image

D. Indicates acceptance of altered appearance and demonstrates positive self-image Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patient's appearance is visibly altered. The face generally appears asymmetric with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patient's level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation.

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. Catch up with the next bag when it arrives. B. Flush the line with 10 mL of sterile saline. C. Request a new bag from the pharmacy department. D. Infuse a solution containing 10% dextrose and water.

D. Infuse a solution containing 10% dextrose and water. 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.

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. Passing into the esophagus C. Irritating the epiglottis D. Inserted into the lungs

D. Inserted into the lungs 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.

The patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? A. Maintain the patient in a high Fowler's position. B. Have the patient pin the tube to the thigh. C. Prime the tubing with 20 mL of normal saline. D. Keep the vent lumen above the patient's stomach level.

D. Keep the vent lumen above the patient's stomach level. The blue vent lumen should be kept above the patient's stomach to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way antireflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, you do not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? A. Giving the feedings at room temperature. B. Administering 15 to 30 mL of water every 4 hours. C. Aspirating for residual contents every 4 to 8 hours. D. Keeping the client in a semi-Fowler's position at all times

D. Keeping the client in a semi-Fowler's position at all times With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.

Immediate medical and nursing management is necessary for a patient who has ingested a corrosive substance and experienced a chemical burn. Select the first response. A. Administer pain medication. B. Rinse the mouth with water to dilute the corrosive agent. C. Treat the patient for shock. D. Maintain a patent airway.

D. Maintain a patent airway. The first priority is to maintain an open airway. The second priority is to treat for shock. The patient should receive nothing by mouth.

An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2° F. Otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? A. Assess the temporomandibular joint for evidence of a malocclusion. B. Test the integrity of the 12th cranial nerve by asking the patient to protrude his tongue. C. Inspect the patient's gums for bleeding and hyperpigmentation. D. Palpate the patient's parotid glands to detect swelling and tenderness.

D. Palpate the patient's parotid glands to detect swelling and tenderness. Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness and swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

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? A. Remove the aspirated fluid and do not reinstill. B. Dilute the gastric tube feeding solution with water and continue the feeding. C. Discontinue the infusion. D. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

D. 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.

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding? A. Parotitis B. Stomatitis C. Pyosis D. Sialadenitis

D. Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? A. Stomatitis B. Sialadenitis C. Parotitis D. Sialolithiasis

D. Sialolithiasis 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.

The nurse attempts to unclog a client's feeding tube. Attempts with warm water agitation and milking the tube are unsuccessful. The nurse uses evidence-based practice principles when subsequently using which technique to unclog the tube? A. meat tenderizer diluted with saline B. sodium bicarbonate mixed with water C. cola mixed with cranberry juice D. digestive enzymes and sodium bicarbonate

D. digestive enzymes and sodium bicarbonate The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable.

The most common symptom of esophageal disease is A. odynophagia. B. vomiting. C. nausea. D. dysphagia.

D. 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.

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

D. 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.

Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition? A. peripherally inserted central catheters B. implanted ports C. tunneled catheters D. nontunneled catheters

D. nontunneled catheters The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, and it allows the client freedom of movement. It also provides easy access to the dressing site. Peripherally inserted central catheter (PICC) lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices used for long-term home IV therapy (e.g., Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).

A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing A. dysphagia. B. odynophagia. C. dyspepsia. D. pyrosis.

D. pyrosis. Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.

To ensure patency of central venous line ports, diluted heparin flushes are used A. with continuous infusions. B. before drawing blood. C. when the line is discontinued. D. when not in use.

D. when not in use. Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance? INPUT FLUID FEED = 480 WATER = 120 IV PB = 50 LIQUID MEDICATION = 60 OUTPUT URINE: 450 The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 ml Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? A. Arterial thrombosis B. Infection C. Venous congestion D. Possible necrosis

A. Arterial thrombosis A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do? A. hang 10% dextrose and water B. stop the infusion and flush the line C. hang 5% dextrose and water D. hang normal saline with potassium

A. hang 10% dextrose and water If the parenteral nutrition (PN) solution runs out and no PN is available, the nurse should hang 10% dextrose and water until the PN becomes available.

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. Empty the Jackson-Pratt device (portable drainage device). D. Provide feeding through the gastrostomy tube.

A. Place the client in the Fowler's position. 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.

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? A. 60 minutes B. 30 minutes C. 80 minutes D. 15 minutes

B. 30 minutes Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.

Which mouth condition is most associated with HIV infection? A. Krythoplakia B. Kaposi sarcoma C. Stomatitis D. Candidiasis

B. Kaposi sarcoma Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion. Of the conditions listed, it is the most associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy. Krythoplakia is caused by a nonspecific inflammation. Candidiasis is caused by fungus.

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. Ensuring adequate nutrition B. Maintaining a patent airway C. Helping the client cope with body image changes D. Preventing injury

B. Maintaining a patent airway 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.

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. 20-mL C. 30-mL D. 10-mL

C. 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.

A nurse is performing an assessment for a client who presents to the clinic with an erythemic, fissuring lip lesion with white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? A. Actinic cheilitis B. Sialadenitis C. Frey syndrome D. Human papillomavirus lesion

A. Actinic cheilitis Actinic cheilitis is an irritation of the lips associated with scaling, crusting, fissure, and overgrowth of a white, horny layer of epidermis (hyperkeratosis). Human papillomavirus lesions appear as flat lesions, small cauliflower-like bumps, or tiny stem-like protrusions. Frey syndrome is damage to the parotid glands after surgery resulting in saliva disturbances. Sialadenitis is an infection associated with pain, tenderness, redness, and gradual, localized swelling affecting the salivary gland.

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication? A. Diuretics B. Steroids C. Antiemetics D. Antibiotics

A. Diuretics Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.

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. 225 mL B. 200 mL C. 150 mL D. 175 mL

A. 225 mL 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.

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? A. Levin tube B. Miller-Abbott tube C. Sengstaken-Blakemore tube D. Salem sump tube

A. Levin tube A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengstaken-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric 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. Decreased bowel sounds B. Diaphoresis C. Tachycardia D. Hypertension E. Diarrhea

B. Diaphoresis C. Tachycardia E. Diarrhea 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.

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. Proton pump inhibitors. B. Antispasmodics C. H2-receptor antagonists. D. Antacids

A. Proton pump inhibitors. Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

A patient with a recent diagnosis of esophageal cancer has undergone an esophagectomy and is currently receiving care in a step-down unit. The nurse in the step-down unit is aware of the specific complications associated with this surgical procedure and is consequently monitoring the patient closely for signs and symptoms of: A. Aspiration pneumonia B. Abdominal aortic aneurysm (AAA) C. Increased intracranial pressure (ICP) D. Dyspepsia

A. Aspiration pneumonia Aspiration pneumonia is a common, and dangerous, post-operative complication following esophagectomy. Increased ICP and AAA are not commonly associated with the procedure, and dyspepsia is not a high-priority concern.

Rebound hypoglycemia is a complication of parenteral nutrition caused by A. feedings stopped too abruptly. B. fluid infusing rapidly. C. glucose intolerance. D. a cap missing from the port.

A. feedings stopped too abruptly. Rebound hypoglycemia occurs when the feedings are stopped too abruptly. 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.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by A. Assessing lung sounds B. Providing fluids to drink C. Preparing for a barium swallow D. Administering the prescribed analgesic

A. 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 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? A. Avoid applying suction on or near the graft site. B. Evaluate the patient's ability to swallow saliva and clear fluids. C. Position patient on his nonoperative side with the head of the bed down. D. Assess viability of the graft before beginning suctioning.

A. 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.

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

A. 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.

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician? A. heart rate of 100 B. blood pressure 118/72 C. urinary output 20 mL/hr D. moist mucous membranes

C. urinary output 20 mL/hr The nurse should notify the physician when the client has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, blood pressure of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit.

The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response? Select all that apply. A. "An anesthetic mouthwash may be used, but I will need to consult with the primary provider." B. "A special diet may be necessary based on your ability to chew and swallow." C. "Cold liquids may help soothe the sensitivity." D. "I can arrange a nutritional consultation." E. "Your health care provider may prescribe a systemic analgesic for pain relief if necessary

A. "An anesthetic mouthwash may be used, but I will need to consult with the primary provider." B. "A special diet may be necessary based on your ability to chew and swallow." D. "I can arrange a nutritional consultation." E. "Your health care provider may prescribe a systemic analgesic for pain relief if necessary The nurse should include the statements, "I can arrange a nutritional consultation," "An anesthetic mouthwash may be used, but I will need to consult with the primary provider," "A special diet may be necessary based on your ability to chew and swallow," and "Your doctor may prescribe a systemic analgesic for pain relief if necessary." These statements describe the management of the plan of care for the client with severe mouth sensitivity. The statement, "Cold liquids may help soothe the sensitivity," should not be included, because cold and hot liquids may increase the discomfort of sensitive oral tissues.

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. 6 B. 2 C. 1 D. 4

A. 6 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.

A public health nurse is participating in a community health fair that is focused on health promotion and illness prevention. Which of the following older adults most likely faces the highest risk of developing oral cancer? A. A man who describes himself as always having been a "heavy smoker and a heavy drinker." B. A woman who is morbidly obese and has a longstanding diagnosis of systemic lupus erythematosus (SLE). C. A woman who describes herself as a "proud breast cancer survivor for over 10 years." D. A man who states that he enjoys good health, with the exception of "heartburn after nearly every meal."

A. A man who describes himself as always having been a "heavy smoker and a heavy drinker." Alcohol and tobacco use are among the major risk factors for oral cancer. Gastrointestinal reflux disease (GERD), SLE, and previous cancer diagnoses are not identified as the most significant risk factors for oral cancer.

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? A. Lithotripsy B. Biopsy C. Radiation D. Chemotherapy

A. 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.

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? A. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. B. Administer the feeding at a warm temperature to decrease peristalsis. C. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. D. Administer the feeding by bolus to prevent continuous intestinal distention.

A. 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.

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. Boerhaave syndrome B. Zenker diverticulum C. Periapical abscess D. Halitosis

A. 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.

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. Esophageal tumor B. Hiatal hernia C. Gastroesophageal reflux disease D. Gastritis

A. 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.

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. Deficient fluid volume C. Impaired urinary elimination D. Risk for imbalanced nutrition, more than body requirements

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 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? A. Hairy leukoplakia B. Erythroplakia C. Aphthous stomatitis D. Nicotine stomatitis

A. 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 client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition? A. Impaired ability to absorb food B. Unwilling to ingest nutrients orally C. Insufficient oral intake D. Prolonged preoperative nutritional needs

A. Impaired ability to absorb food A client with Crohn's disease will have an impaired ability to ingest or absorb food orally or enterally. Clients with severe burns, malnutrition, short-bowel syndrome, AIDS, sepsis, and cancer would need parenteral nutrition because of insufficient oral intake. Unwillingness to ingest nutrients orally would cause a client with a major psychiatric illness to need parenteral nutrition. Prolonged surgical nutritional needs such as what occurs after extensive bowel surgery or acute pancreatitis would necessitate the need for parenteral nutrition.

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. Little food in the working refrigerator C. Electricity that loses power, usually for short duration, during storms D. Water of low pressure that can be obtained through all faucets

A. No land line; cell phone available and taken by family member during working hours 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 has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply. A. Observe for respiratory distress. B. Monitor aspirate for sudden change in amount. C. Mark the tube at the exit site. D. Measure pH of feeding tube aspirates. E. Auscultate. F. Obtain radiographic confirmation.

A. Observe for respiratory distress. B. Monitor aspirate for sudden change in amount. C. Mark the tube at the exit site. D. Measure pH of feeding tube aspirates. F. Obtain radiographic confirmation. The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? A. Provide frequent mouth care. B. Ensure adequate hydration with additional water. C. Flush the tube with water before adding the feedings. D. Keep the feeding formula refrigerated.

A. Provide frequent mouth care. Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

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 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.

Which clinical manifestation is not associated with hemorrhage? A. Hypotension B. Bradycardia C. Tachycardia D. Tachypnea

B. Bradycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to A. Inspect the nose daily for skin irritation. B. Apply water-based lubricant to the nares daily. C. Auscultate lung sounds every 4 hours. D. Change the nasal tape every 2 to 3 days.

C. Auscultate lung sounds every 4 hours. 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.

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

C. 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.

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 A. Administers the feeding at a cooler temperature B. Increases the amount of feeding at the next feeding C. Consults with the physician about decreasing the feeding to half-strength D. Discusses with the nutritionist about increasing the osmolality of the feeding

C. 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.

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? A. Air insufflation B. Digestive enzyme mixed with warm water C. Cranberry juice D. Commercial enzyme product

C. 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.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: A. Encourage the client to position himself on his side. B. Provide oxygen without humidity through the tracheostomy tube. C. Make a notation on the call light system that the client cannot speak. D. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery.

C. Make a notation on the call light system that the client cannot speak. 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.

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

C. 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 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. Tunneled central catheter B. Nontunneled central catheter C. Peripherally inserted central catheter (PICC) D. Implanted port

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.

A 54 year-old man is postoperative day 1 following neck dissection surgery. Which of the following nursing actions should the nurse prioritize in the care of this patient? A. Maintaining protective isolation for 24 to 36 hours after surgery B. Ensuring that naloxone (Narcan) is available at the patient's bedside C. Positioning the patient in a high Fowler's position to protect the airway D. Teaching the patient about the signs and symptoms of major postoperative complications

C. Positioning the patient in a high Fowler's position to protect the airway Protection of the patient's airway is a priority over patient education, even though patient education is an appropriate and relevant measure. It is not normally necessary to keep naloxone at the bedside or to establish protective isolation.

An older client is diagnosed with parotitis. What bacterial infection does the nurse suspect caused the client's parotitis? A. Streptococcus viridans B. Pneumococcus C. Staphylococcus aureus D. Pseudomonas

C. Staphylococcus aureus 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.

Which of the following is the most common type of diverticulum? A. Mid-esophageal B. Intramural C. Zenker's diverticulum D. Epiphrenic

C. 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).

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? A. 50 to 75 mL B. 20 to 40 mL C. 160 to 200 mL D. 80 to 120 mL

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

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? A. Instruct the client to swallow several times. B. Have the client lay on the left side. C. Assist the client to drink 8 ounces of water. D. Administer prescribed metoclopramide.

D. Administer prescribed metoclopramide. Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on the right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum.

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? A. Actinic cheilitis B. Leukoplakia C. Lichen planus D. Chancre

D. Chancre 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.

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. This is a normal occurrence and the tube should be left in place. C. The tube is most likely defective and should be immediately removed. D. The nurse has inadvertently inserted the tube into the trachea.

D. 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.

The primary source of microorganisms for catheter-related infections are the skin and the A. IV fluid bag. B. catheter tubing. C. IV tubing. D. catheter hub.

D. catheter hub. 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 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. Roof of the mouth next to the incisors C. Posterior segment of the tongue near the uvula D. Dorsum of the tongue

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.