Med Surg Chapter 39

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?

A canker sore of the oral soft tissues

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

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

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?

30-mL

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?

Apply pressure to the bleeding site

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?

Baking soda and water

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.

Calorie counts for oral nutrients, Daily weights, Intake and output monitoring

A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate?

Check with the pharmacist to see of a liquid form is available

The nurse is caring for a client who requires enteral nutrition. For which reasons will the nurse anticipate the client having a gastrostomy tube inserted? Select all that apply.

Client is comatose, Enteral support needed for over 6 weeks

The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client?

Diagnosed with malabsorption syndrome

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Diarrhea

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?

Dumping syndrome

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?

Dysphagia

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water

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?

Exhibiting hemoglobin A1C 8.2

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?

Gastroesophageal reflux disease (GERD)

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration

During a psychotic episode, a client with schizophrenia swallows a small wooden spoon. Which medication would the nurse in the emergency department be most likely to administer to facilitate removal of the foreign body?

Glucagon

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

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

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

Ineffective airway clearance related to obstruction by mucus

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?

Keep the vent lumen above the patient's stomach level

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

Lithotripsy

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?

Maintaining a patent airway

The nurse provides health teaching to inform the client with oral cancer that

Many oral cancers produce no symptoms in the early stages

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):

Protrusion of the upper stomach into the lower portion of the thorax

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?

Provide frequent mouth care

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?

Remaining upright for at least 1 hour following each meal

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

Remove gas and fluids from the stomach, Diagnose gastrointestinal motility disorders, Administer nutritional substances, Flush ingested toxins from the stomach

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?

Staphylococcus aureus

Which term describes an inflammation of the salivary glands?

Stomatitis

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.

Tachycardia, Diarrhea, Diaphoresis

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?

The client is free from esophagitis and achalasia

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?

Uncontrolled rhythmic movements of the face or limbs

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n)

chancre

To ensure patency of central venous line ports, diluted heparin flushes are used

daily, when not in use

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?

metoclopramide

The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is

shoulder drop

The most significant complication related to continuous tube feedings is

the increased potential for aspiration