Prep U - Ch 45

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? Summon assistance Apply pressure to the bleeding site Elevate the head of the patient's bed Notify the surgeon to repair the vessel

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

Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

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

Avoid beer, especially in the evening, elevate the head of the bed on 6- to 8- inch blocks, elevate the upper body on pillows Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? Eliminating spicy foods. Avoiding chocolate and coffee. Eliminating cucumbers and other foods with seeds. Avoiding steamed foods.

Avoiding chocolate and coffee Chocolate, tea, cola, and caffeine lower esophageal sphincter pressure, thereby increasing reflux. Clients do not need to eliminate spicy foods unless such foods bother them. Foods with seeds are restricted in diverticulosis. Steamed foods are encouraged to retain vitamins and decrease fat intake.

The nurse is 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? Dextrose and water Baking soda and water Full-strength peroxide Mouthwash and water

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.

Which clinical manifestation is not associated with hemorrhage? Tachycardia Bradycardia Tachypnea Hypotension

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 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? Buccal mucosa next to the upper molars Dorsum of the tongue Roof of the mouth next to the incisors Posterior segment of the tongue near the uvula

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.

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

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.

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastroesophageal reflux disease Peptic ulcer with melena Diverticulitis with perforation Gastritis

GERD Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Increasing difficulty in swallowing Sensation of a mass in throat Foul breath Hiccups

Increasing difficulty in swallowing The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.

Which mouth condition is most associated with HIV infection? Kaposi sarcoma Stomatitis Krythoplakia Candidiasis

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.

Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium) Famotidine (Pepcid) Nizatidine (Axid)

Lansoprazole (prevacid), rabeprazole (aciphex), esomeprazole (nexium)

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

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

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

Metoclopramide (Reglan) Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route? nasogastric intubation orogastric intubation nasoenteric intubation gastrostomy

Nasogastric intubation The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.

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? Document the presence of stridor Administer a breathing treatment Notify the physician Lower the head of the bed

Notify the physician The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Nystatin Cephalexin Fluocinolone acetonide oral base gel Acyclovir

Nystatin Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Buccal Parotid Sublingual Submandibular

Parotid The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? Place the client in the Fowler's position. Administer morphine for report of pain. Provide feeding through the gastrostomy tube. Empty the Jackson-Pratt device (portable drainage device).

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.

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: H2-receptor antagonists. Antispasmodics Proton pump inhibitors. Antacids

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

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): Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm.

Protrusion of the upper stomach into the lower portion of the thorax It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

Which of the following refers to a bacterial or viral infection of the salivary glands? Sialadenitis Parotitis Mumps Stomatitis

Sialadentitis Sialadenitis refers to the bacterial or viral infection of the salivary glands. Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands. Mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting children, is an inflammation of a salivary gland, usually the parotid. Stomatitis involves inflammation and breakdown of the oral mucosa; it is often a side effect of chemotherapy or radiation therapy.

Select the assessment finding that the nurse should immediately report, post radical neck dissection. Temperature of 99°F Pain Stridor Localized wound tenderness

Stridor Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge? Hold his breath Take long, slow breaths Bear down as if having a bowel movement Pant like a dog

Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

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? Serosanguineous drainage on the dressing Foley catheter bag containing 500 ml of amber urine A piggyback infusion of levofloxacin The client lying in a lateral position, with the head of bed flat

The client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

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: there are usually no symptoms. symptoms include mouth pain. symptoms include oral bleeding. symptoms include oral numbness.

There are usually no symptoms The early stage of oral cancer is characteristically asymptomatic.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? Anxiety or irritability Hyperactivity Uncontrolled rhythmic movements of the face or limbs Dry mouth not relieved by sugar-free hard candy

Uncontrolled rhythmic movements of the face or limbs Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery? Vagus Hypoglossal Vestibulocochlear Trigeminal

Vagus Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

Which of the following is the most common type of diverticulum? Zenker's diverticulum Mid-esophageal Epiphrenic Intramural

Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

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? Between 40 and 80 mL Approximately 80 to 120 mL Between 120 and 160 mL Greater than 160 mL

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.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Consume foods containing peppermint or spearmint. Avoid eating or drinking 2 hours before bedtime. Elevate the foot of the bed on 6- to 8-inch blocks. Eat a low-carbohydrate diet.

Avoid eating or drinking 2 hours before bedtime The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head of the bed on 6- to 8-inch blocks.

A client comes to the clinic complaining of a sore throat. When assessing the client, the nurse observes a reddened ulcerated lesion on the lip. The client tells the nurse that it has been there for a couple of weeks but it does not hurt. What should the nurse consult with the health care provider about testing for? HIV Syphilis Gonorrhea Herpes simplex

Syphilis The primary lesion of syphilis is a chancre, which is a reddened circumscribed lesion that ulcerates and becomes crusted.

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? a low-fat diet elevation of upper body on pillows pantoprazole metoclopramide

Metoclopramide The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Hiatal hernia Gastroesophageal reflux disease Gastritis Esophageal tumor

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.

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? Halitosis Zenker diverticulum Boerhaave syndrome Periapical abscess

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.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client? Urge the client to regularly rinse the mouth with tap water. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. Provide the client with an irrigating solution of baking soda and warm water. Regularly wipe the outside of the client's mouth to prevent germs from entering.

Provide the client with an irrigating solution of baking soda and warm water If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.

Which term describes an inflammation of the salivary glands? Parotitis Sialadenitis Stomatitis Pyosis

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 of the following are functions of saliva? Select all that apply. Lubrication Protection against harmful bacteria Digestion Elimination Metabolism

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

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

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.

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

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.

An adolescent client with multiple dental caries is discussing diet with the nurse. What client statement identifies a risk factor for dental caries? "I brush my teeth in the morning and evening." "I drink a can of carbonated soda at lunch every day." "I floss before I go to bed each night." "I visit my dentist every year."

"I drink a can of carbonated soda at lunch every day" The client's statement of drinking a carbonated soda with refined sugar at lunch every day puts the client at risk for dental caries. The other statements are measures to prevent dental caries, including brushing teeth after meals, flossing daily, and having regular dental visits.

The most common symptom of esophageal disease is nausea. vomiting. dysphagia. odynophagia.

Dysphagia Dysphagia may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.

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

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.

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

"Avoid coffee and alcoholic beverages" To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat three large meals every day without any food restrictions." "I'll lie down immediately after a meal." "I'll gradually increase the amount of heavy lifting I do." "I'll eat frequent, small, bland meals that are high in fiber."

"I'll eat frequent, small, bland meals that are high in fiber" In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

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? Actinic cheilitis Human papillomavirus lesion Frey syndrome Sialadenitis

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 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? Aphthous stomatitis Kaposi's sarcoma Chancre Hairy leukoplakia

Aphthous stomatitis Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.

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? Assess lung sounds bilaterally. Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

Assess lung sounds bilaterally All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

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

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 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? Use a hard-bristled toothbrush. Rinse with an alcohol-based solution. Brush and floss daily. Continue with the usual diet.

Brush and floss teeth 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 the primary symptom of achalasia? Difficulty swallowing Chest pain Heartburn Pulmonary symptoms

Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

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

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.

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 Drinking fluoridated water Eating fruits and cheese in diet Using a soft-bristled toothbrush

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 new order for metoclopramide. What potential side effects should the nurse educate the client about? Extrapyramidal Peptic ulcer disease Gastric slowing Nausea

Extrapyramidal Metoclopramide (Reglan) is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

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

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 describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Peptic ulcer disease Esophageal cancer Gastroesophageal reflux disease Diverticulitis

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

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 Insulin Haloperidol Epinephrine

Glucagon Glucagon is administered before removing a foreign body because it relaxes the smooth muscle of the esophagus, thereby facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Insulin and epinephrine would not assist with foreign body removal.

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? Aphthous stomatitis Nicotine stomatitis Erythroplakia Hairy leukoplakia

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.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician? High epigastric pain and/or discomfort Crackles that clear after coughing Serous drainage on the dressing Temperature of 99.0°F (37.2°C)

High epigastric pain and/or discomfort The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.

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? Instruct the client to swish prescribed nystatin solution for 1 minute. Remove the plaque from the mouth by rubbing with gauze. Provide saline rinses prior to meals. Encourage the client to ingest a soft or bland diet.

Instruct the client to swish prescribed nystatin solution for 1 minute A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.

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? Helping the client cope with body image changes Ensuring adequate nutrition Maintaining a patent airway Preventing injury

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

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.

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? Methicillin-resistant Streptococcus aureus (MRSA) Pneumococcus Staphylococcus aureus Streptococcus viridans

Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).

The client has a chancre on the lips. What instruction should the nurse provide? Apply warm soaks to the lip. Gargle with an antiseptic solution. Avoid foods that could irritate the lesion. Take measures to prevent spreading the lesion to other people.

Take measures to prevent spreading the lesion to other people A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.