Chapter 39
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 is a vent that prevents backflow of the secretions." b. "It acts as a siphon, pulling secretions into the clear tubing." c. "It helps regulate the pressure on the suction machine." d. "It works as a marker to make sure that the tube stays in place."
"It is a vent that prevents backflow of the secretions."
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
1 hour
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. 15 minutes b. 30 minutes c. 60 minutes d. 80 minutes:
30 minutes
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? a. 5-mL b. 10-mL c. 20-mL d. 30-mL
30-mL
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? a. 4 p.m. to 6 p.m. b. 6 p.m. to 8 p.m. c. 8 p.m. to 10 p.m. d. 10 p.m. to 12 a.m
6 p.m. to 8 p.m.
A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what? A) Presence of small blood clots in the drainage B) 60 mL of milky or cloudy drainage C) Spots of drainage on the dressings surrounding the drain D) 120 mL of serosanguinous drainage
60 mL of milky or cloudy drainage
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. 20 to 40 mL b. 50 to 75 mL c. 80 to 120 mL d. 160 to 200 mL
80 to 120 mL
A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A) A 65-year-old man with alcoholism who smokes B) A 45-year-old woman who has type 1 diabetes and who wears dentures C) A 32-year-old man who is obese and uses smokeless tobacco D) A 57-year-old man with GERD and dental caries
A 65-year-old man with alcoholism who smokes
Which of the following are functions of saliva? Select all that apply. a. Lubrication b. Protection against harmful bacteria c. Digestion d. Elimination e. Metabolism:
A,B,C
The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply. a. Weigh the client every day. b. Check blood glucose level every 6 hours. c. Cover insertion site with a transparent dressing that is changed daily. d. Use clean technique for all catheter dressing changes. e. Document intake and output.
A,B,E
A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply. A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus
A,C,E
A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate? a. Achalasia b. Diffuse spasm c. Gastroesophageal reflex disease d. Hiatal hernia
Achalasia
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 at a warm temperature to decrease peristalsis. b. Administer the feeding by bolus to prevent continuous intestinal distention. c. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. d. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time
Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time
A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time? A) Emotional support from visitors and staff B) An effective means of communicating with the nurse C) Referral to a speech therapist D) Dietary teaching focused on consistency of food and frequency of feedings
An effective means of communicating with the nurse
A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? A) A patient who is receiving intravenous antibiotic therapy in the home setting B) A patient who has a chronic venous ulcer C) An older adult whose medication regimen includes an anticholinergic D) A patient with poorly controlled diabetes who receives weekly wound care
An older adult whose medication regimen includes an anticholinergic
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
Assessing lung sounds
A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery? A) Assessing function of cranial nerves V, VI, and IX B) Assessing for a history of GERD C) Assessing for signs or symptoms of atherosclerosis D) Assessing the patency of the ulnar artery
Assessing the patency of the ulnar artery
The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings? a. Aphthous stomatitis b. Kaposi's sarcoma c. Chancre d. Hairy leukoplakia
Aphthous stomatitis
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A) Assess ability to clear oral secretions B) Assess for signs of infection. C) Assess for a patent airway. D) Assess for ability to communicate.
Assess for a patent airway
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? a. Assess lung sounds bilaterally. b. Administer prescribed morphine intravenously. c. Obtain consent for the esophagogastroscopy. d. Suction the oral cavity of the client.
Assess lung sounds bilaterally.
A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? a. Reinforce the neck dressing when blood is present on the dressing. b. Assess the graft for color and temperature. c. Administer prescribed intravenous vancomycin at the correct time. d. Cleanse around the drain using aseptic technique.
Assess the graft for color and temperature.
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a. Apply water-based lubricant to the nares daily. b. Auscultate lung sounds every 4 hours. c. Inspect the nose daily for skin irritation. d. Change the nasal tape every 2 to 3 days.
Auscultate lung sounds every 4 hours
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 suture line. B) Position patient on the non operative side with the head of the bed down. C) Assess the patients ability to perform self-suctioning. D) Evaluate the patients ability to swallow saliva and clear fluids.
Avoid applying suction on or near the suture line
A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A) Keep the head of the bed lowered. B) Drink a cup of hot tea before bedtime. C) Avoid carbonated drinks. D) Eat a low-protein diet.
Avoid carbonated drinks.
A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? A) Increasing calcium intake to promote bone healing B) Avoiding chewing food for the specified number of weeks after surgery C) Techniques for managing parenteral nutrition in the home setting D) Techniques for managing a gastrostomy
Avoiding chewing food for the specified number of weeks after surgery
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. a. Assess for patency of the peripheral intravenous site b. Ensure availability of an infusion pump c. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel d. Administer the intravenous antibiotic in the same tubing as the parenteral nutrition e. Place a 1.5-micron filter on the tubing
B,C,E
Which clinical manifestation is not associated with hemorrhage? a. Tachycardia b. Bradycardia c. Tachypnea d. Hypotension
Bradycardia
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. Brush and floss daily. d. Continue with the usual diet
Brush and floss daily.
A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? A) Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash B) Applying a water-soluble gel to the teeth and gums C) Wiping the teeth and gums clean with a gauze pad D) Brushing the patients teeth with a toothbrush and small amount of toothpaste
Brushing the patients teeth with a toothbrush and small amount of toothpaste
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? a. Lichen planus b. Actinic cheilitis c. Chancre d. Leukoplakia
Chancre
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? a. Call the physician. b. Apply a dry sterile dressing to the site. c. Clamp the catheter. d. Tell the client to take and hold a deep breath
Clamp the catheter
A client's new onset of dysphagia has required insertion of an NG tube for feeding. What intervention should the nurse include in the client's plan of care? a. Confirm placement of the tube prior to each scheduled feeding. b. Have the client sip cool water to stimulate saliva production. c. Keep the client in a low Fowler position when at rest. d. Connect the tube to continuous wall suction when not in use.
Confirm placement of the tube prior to each scheduled feeding.
The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? a. History of diverticulitis b. Treatment for internal hemorrhoids c. Polyps removed during a colonoscopy d. Diagnosed with malabsorption syndrome:
Diagnosed with malabsorption syndrome:
A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? a. Diverticulosis b. Paralytic ileus c. Dumping syndrome d. Small bowel obstruction
Dumping syndrome
A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? A) Promotion of a nutrient-dense, low-fat diet B) Annual screening endoscopy for patients over 50 with a family history of esophageal cancer C) Early diagnosis and treatment of gastroesophageal reflux disease D) Adequate fluid intake and avoidance of spicy foods
Early diagnosis and treatment of gastroesophageal reflux disease
A nurse is caring for a patient who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite? A) Encourage the family to bring in the patients favored foods. B) Limit visitors at mealtimes so that the patient is not distracted. C) Avoid offering food unless the patient initiates. D) Provide thorough oral care immediately after the patient eats.
Encourage the family to bring in the patients favored foods.
A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients longterm needs, the nurse should prioritize interventions and referrals with what goal? A) Enhancement of verbal communication B) Enhancement of immune function C) Maintenance of adequate social support D) Maintenance of fluid balance
Enhancement of verbal communication
A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? A) Ensure that none of the patients visitors has an infection. B) Arrange for a diet that is high in protein and low in fat. C) Administer colony stimulating factors (CSFs) as ordered. D) Prepare to administer chemotherapeutics as ordered
Ensure that none of the patients visitors has an infection.
An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom? a. Hiatal hernia b. Gastroesophageal reflux disease c. Gastritis d. Esophageal tumor
Esophageal tumor
Cancer of the esophagus is most often diagnosed by which of the following? a. Esophagogastroduodenoscopy (EGD) with biopsy and brushings b. X-ray c. Barium swallow d. Fluoroscopy
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
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. Exhibiting hemoglobin A1C 8.2 b. Drinking fluoridated water c. Eating fruits and cheese in diet d. Using a soft-bristled toothbrush
Exhibiting hemoglobin A1C 8.2
A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action? a. Assess the client's appetite. b. Assist the client into a supine position. c. Apply topical anesthetic to the client's nares as prescribed. d. Explain the process clearly to the client.
Explain the process clearly to the client
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? a. Remove the tape from the nose of the client. b. Withdraw the tube gently for 6 to 8 inches. c. Provide oral hygiene. d. Flush with 10 mL of water.
Flush with 10 mL of water
A nurse is providing care for a client with a diagnosis of late-stage Alzheimer disease. The client has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? a. Frequent assessment of the client's abdominal girth b. Assessment for hemorrhage from the nasal insertion site c. Frequent lung auscultation d. Vigilant monitoring of the frequency and character of bowel movements
Frequent lung auscultation
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: a. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. b. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. c. Feedings can be administered with the patient in the recumbent position. d. The patient cannot experience the deprivational stress of not swallowing.
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.
An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A) Haloperidol B) Prostigmine C) Epinephrine D) Glucagon
Glucagon
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. Aphthous stomatitis b. Nicotine stomatitis c. Erythroplakia d. Hairy leukoplakia
Hairy leukoplakia
A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? A) Ineffective Tissue Perfusion B) Impaired Skin Integrity C) Aspiration D) Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: Less Than Body Requirements
A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries? A) Hormonal changes brought on by the stress response cause an acidic oral environment B) Systemic infections frequently migrate to the teeth C) Hydration that is received intravenously lacks fluoride D) Inadequate nutrition and decreased saliva production can cause cavities
Inadequate nutrition and decreased saliva production can cause cavities
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? a. Increasing difficulty in swallowing b. Sensation of a mass in throat c. Foul breath d. Hiccups
Increasing difficulty in swallowing
A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated 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) Indicates acceptance of altered appearance and demonstrates positive self-image B) Freely expresses needs and concerns related to postoperative pain management C) Compensates effectively for alteration in ability to communicate related to dysarthria D) Demonstrates effective stress management techniques to promote muscle relaxation
Indicates acceptance of altered appearance and demonstrates positive self-image
A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A) Risk for Disuse Syndrome B) Unilateral Neglect C) Risk for Trauma D) Ineffective Tissue Perfusion
Ineffective Tissue Perfusion
A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A) Drinking beverages after your meal, rather than with your meal, may bring some relief. B) Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow. C) Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating. D) Instead of eating three meals a day, try eating smaller amounts more often.
Instead of eating three meals a day, try eating smaller amounts more often.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? a. Instruct the client to swish prescribed nystatin solution for 1 minute. b. Remove the plaque from the mouth by rubbing with gauze. c. Provide saline rinses prior to meals. d. Encourage the client to ingest a soft or bland diet.
Instruct the client to swish prescribed nystatin solution for 1 minute.
A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is most appropriate? a. Stop the tube feed and aspirate stomach contents. b. Increase the hourly feed rate so it finishes earlier. c. Keep the client in semi-Fowler position for 1 hour after feedings d. Administer fluid replacement by IV
Keep the client in semi-Fowler position for 1 hour after feedings
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? a. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. b. Keep the vent lumen above the patient's waist to prevent gastric content reflux. c. Irrigate only through the vent lumen. d. Tape the tube to the head of the bed to avoid dislodgement.
Keep the vent lumen above the patient's waist to prevent gastric content reflux.
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. Aspirating for residual contents every 4 to 8 hours. b. Administering 15 to 30 mL of water every 4 hours. c. Giving the feedings at room temperature. d. Keeping the client in a semi-Fowler's position at all times.
Keeping the client in a semi-Fowler's position at all times
Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? A) Eating several small meals daily rather than 3 larger meals B) Keeping the head of the bed slightly elevated C) Drinking carbonated mineral water rather than soft drinks D) Avoiding food or fluid intake after 6:00 p.m.
Keeping the head of the bed slightly elevated
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. Salem sump tube b. Miller-Abbott tube c. Sengstaken-Blakemore tube d. Levin tube
Levin tube
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? a. Radiation b. Lithotripsy c. Chemotherapy d. Biopsy
Lithotripsy
A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A) Pyloric sphincter B) Lower esophageal sphincter C) Hypopharyngeal sphincter D) Upper esophageal sphincter
Lower esophageal sphincter
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? a. Helping the client cope with body image changes b. Ensuring adequate nutrition c. Maintaining a patent airway d. Preventing injury
Maintaining a patent airway
A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A) Radiation therapy often results in secondary brain tumors. B) Surgical complications are exceedingly common. C) Diagnosis rarely occurs until the cancer is endstage. D) Metastases are common and respond poorly to treatment.
Metastases are common and respond poorly to treatment.
A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? A) Metoclopramide (Reglan) B) Omeprazole (Prilosec) C) Lansoprazole (Prevacid) D) Famotidine (Pepcid)
Metoclopramide (Reglan)
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? a. Metoclopramide (Reglan) b. Famotidine (Pepcid) c. Nizatidine (Axid) d. Esomeprazole (Nexium):
Metoclopramide (Reglan)
A client is receiving continuous tube feedings at 75 mL/h. When the nurse checked the residual volume 4 hours ago, it was 250 mL, and now the residual volume is 325 mL. What is the priority action by the nurse? a. Discard the residual volume. b. Stop the continuous feeding. c. Decrease the rate to 40 mL/h. d. Notify the healthcare provider.
Notify the healthcare provider
The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? a. Document the presence of stridor b. Administer a breathing treatment c. Notify the physician d. Lower the head of the bed
Notify the physician
The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay? A) Organic fruit juice B) Roasted nuts C) Red meat that is high in fat D) Cheddar cheese
Organic fruit juice
An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and 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) Palpate the patients parotid glands to detect swelling and tenderness. B) Assess the temporomandibular joint for evidence of a malocclusion. C) Test the integrity of cranial nerve XII by asking the patient to protrude the tongue. D) Inspect the patients gums for bleeding and hyperpigmentation
Palpate the patients parotid glands to detect swelling and tenderness
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? a. Place the client in the Fowler's position. b. Administer morphine for report of pain. c. Provide feeding through the gastrostomy tube. d. Empty the Jackson-Pratt device (portable drainage device).
Place the client in the Fowler's position.
A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? A) Placing the patient in a left lateral position B) Administering opioids as ordered C) Placing the patient in Fowlers position D) Teaching the patient to use the patient-controlled analgesia (PCA) system
Placing the patient in Fowlers position
A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care? A) Teaching the patient to self-suction B) Performing chest physiotherapy to promote oxygenation C) Positioning the patient to prevent gastric reflux D) Providing a regular diet as tolerated
Positioning the patient to prevent gastric reflux
The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? A) Dull pain radiating to the ears and teeth B) Presence of a painless sore with raised edges C) Areas of tenderness that make chewing difficult D) Diffuse inflammation of the buccal mucosa
Presence of a painless sore with raised edges
A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? A) Muscle training to relieve dysphagia B) Relieving nerve paralysis in the cervical plexus C) Promoting maximum shoulder function D) Alleviating achalasia by decreasing esophageal peristalsis
Promoting maximum shoulder function
A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education? A) Resumption of activities of daily living B) Pain control C) Promotion of adequate nutrition D) Strategies for promoting communication
Promotion of adequate nutrition
A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action? A) Document the findings as being consistent with a viable graft. B) Promptly report these indications of venous congestion. C) Closely monitor the patient and reassess in 30 minutes. D) Reposition the patient to promote peripheral circulation.
Promptly report these indications of venous congestion
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): a. Extension of the esophagus through an opening in the diaphragm. b. Involution of the esophagus, which causes a severe stricture. c. Protrusion of the upper stomach into the lower portion of the thorax. d. Twisting of the duodenum through an opening in the diaphragm.
Protrusion of the upper stomach into the lower portion of the thorax.
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. pyrosis. b. dyspepsia. c. dysphagia. d. odynophagia
Pyrosis
A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom? A) Burning pain on swallowing B) Regurgitation of undigested food C) Symptoms mimicking a heart attack D) Chronic parotid abscesses
Regurgitation of undigested food
A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action? A) Encourage the patient to perform deep breathing and coughing exercises hourly. B) Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula. C) Activate the emergency response system. D) Report this finding promptly to the physician and remain with the patient.
Report this finding promptly to the physician and remain with the patient.
A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? A) Presence of acute pain and anxiety B) Tissue integrity and color of the operative site C) Respiratory status and airway clearance D) Self-esteem and body image
Respiratory status and airway clearance
A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care? A) Risk for Aspiration Related to Inhalation of Gastric Contents B) Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption C) Risk for Decreased Cardiac Output Related to Vasovagal Response D) Risk for Impaired Verbal Communication Related to Oral Trauma
Risk for Aspiration Related to Inhalation of Gastric Contents
Which term describes an inflammation of the salivary glands? a. Parotitis b. Sialadenitis c. Stomatitis d. Pyosis
Sialadenitis
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis? a. Methicillin-resistant Streptococcus aureus (MRSA) b. Pneumococcus c. Staphylococcus aureus d. Streptococcus viridans
Staphylococcus aureus
The client has a chancre on the lips. What instruction should the nurse provide? a. Apply warm soaks to the lip. b. Gargle with an antiseptic solution. c. Avoid foods that could irritate the lesion. d. Take measures to prevent spreading the lesion to other people
Take measures to prevent spreading the lesion to other people
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. A length of 50 cm (20 in) b. 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 d. The distance determined by measuring from the tragus of the ear to the xiphoid process
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The patient will require an upper endoscopy every 6 months to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside.
The patient will require an upper endoscopy every 6 months to detect malignant changes.
A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A) The patients swallowing ability B) The patients ability to speak C) The patients management of secretions D) The patients airway patency
The patients swallowing ability
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location? a. Tip of patient's nose b. Tragus of the ear c. Base of the neck d. Tip of the xiphoid process
Tip of patient's nose
A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions? A) Rinse the mouth with alcohol before bedtime for the next 7 days. B) Use warm saline to rinse the mouth as needed. C) Brush around the area with a firm toothbrush to prevent infection. D) Use a toothpick to dislodge any debris that gets lodged in the socket
Use warm saline to rinse the mouth as needed
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? a. Administer antibiotics via the tube as prescribed. b. Wash the area around the tube with soap and water daily. c. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. d. Irrigate the skin surrounding the insertion site with normal saline before each use.
Wash the area around the tube with soap and water daily.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? a. Abdominal distention, elevated temperature, weakness before eating b. Constipation, rectal bleeding following bowel movements c. Persistent loose stools, chills, hiccups after eating d. Weakness, diaphoresis, diarrhea 90 minutes after eating
Weakness, diaphoresis, diarrhea 90 minutes after eating
A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action: a. Cleanses the insertion site with a chlorhexidine solution b. Uses a circular motion from insertion site outward c. Wipes catheter ports from distal end to insertion site d. Contaminates gloves and obtains a pair of sterile gloves for use
Wipes catheter ports from distal end to insertion site
Which of the following is the most common type of diverticulum? a. Zenker's diverticulum b. Mid-esophageal c. Epiphrenic d. Intramural
Zenker's diverticulum
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n) a. lichen planus. b. actinic cheilitis. c. chancre. d. leukoplakia.
chancre
What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? a. continuous feedings b. intermittent feeding c. bolus feeding d. cyclic feeding
continuous feedings
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? a. diaphoresis, vomiting, and diarrhea. b. manifestations of electrolyte disturbances. c. manifestations of hypoglycemia. d. constipation, dehydration, and hypercapnia.
diaphoresis, vomiting, and diarrhea.
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.
the increased potential for aspiration.
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: a. place the client in a supine position and prepare to perform cardiopulmonary resuscitation. b. place the client in high-Fowler's position and administer supplemental oxygen. c. turn the client on his left side and place the bed in Trendelenburg's position. d. position the client in the shock position with his legs elevated.
turn the client on his left side and place the bed in Trendelenburg's position.
