CH. 39 Study guide

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol." B. "The only time I flush my tube is when I'm putting in medications." C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."

"I flush my tube with water before and after each of my medications."

A client 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. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients 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 who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A. "It eliminates the risk for infection." B. "Feeds can be infused at a faster rate." C. "Regurgitation and aspiration are less likely." D. "It allows caregivers to provide personal hygiene more easily."

"Regurgitation and aspiration are less likely."

A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) 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

- Perforation into the mediastinum - Erosion into the great vessels - Obstruction of the esophagus

A client 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 health care provider immediately for what finding? 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 nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client 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

The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication. B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.

Administer each medication separately.

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea

Aspiration

A nurse is assessing a client 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's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

The nurse determines that a client who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the nurse's priority when suctioning this client? A. Avoid applying suction on or near the suture line. B. Position client on the non-operative side with the head of the bed down. C. Assess the client's ability to perform self-suctioning. D. Evaluate the client's ability to swallow saliva and clear fluids.

Avoid applying suction on or near the suture line.

A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this client, 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

The nurse is caring for a client who had a low-profile gastrostomy device placed. Which instruction should the nurse give the client and family? A. Wear the tubing outside of clothing. B. Use tape to secure the device. C. Bring the connection tubing if going to the hospital. D. Change the wet-to-dry dressing daily.

Bring the connection tubing if going to the hospital.

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 should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat diet B. Annual screening endoscopy for clients 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 The client is experiencing painful oral lesions following radiation for oropharyngeal cancer. Which instruction should the nurse give this client? A. Spicy foods stimulate salivation and are soothing. B. Eat food while it is hot to enhance flavor. C. Avoid brushing teeth while lesions are present. D. Eat soft or liquid foods.

Eat soft or liquid foods.

A nurse is caring for a client who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the client's appetite? A. Encourage the family to bring in the client's favorite foods. B. Limit visitors at mealtimes so that the client is not distracted. C. Avoid offering food unless the client initiates. D. Provide thorough oral care immediately after the client eats.

Encourage the family to bring in the client's favorite foods.

A nurse is caring for a client who has had surgery for oral cancer. When addressing the client's long-term 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

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 nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for 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 medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client? 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 client 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 nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube. D. Topical anesthetics will be used to reduce discomfort during insertion.

Insertion is likely to cause some gagging.

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? A. Measure and record drainage. B. Monitor drainage for change in color. C. Titrate the suction every hour. D. Feed the client via the G tube as prescribed.

Measure and record drainage.

A client 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 end stage. D. Metastases are common and respond poorly to treatment.

Metastases are common and respond poorly to treatment.

A client 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 client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

Metoclopramide

A client 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 client? A. Placing the client in a left lateral position B. Administering opioids as prescribed C. Placing the client in Fowler position D. Teaching the client to use the client-controlled analgesia (PCA) system

Placing the client in Fowler position

A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care? A. Teaching the client to self-suction B. Performing chest physiotherapy to promote oxygenation C. Positioning the client to prevent gastric reflux D. Providing a regular diet as tolerated

Positioning the client to prevent gastric reflux

A client 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 should the goals of physical therapy for this client 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 client 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 client's 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 client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's 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 client and reassess in 30 minutes. D. Reposition the client to promote peripheral circulation.

Promptly report these indications of venous congestion.

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? A. Burning pain on swallowing B. Regurgitation of undigested food C. Symptoms mimicking a myocardial infarction D. Chronic parotid abscesses

Regurgitation of undigested food

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? A. Encourage the client to perform deep breathing and coughing exercises hourly. B. Reposition the client into a prone or semi-Fowler position and apply supplementary oxygen by nasal cannula. C. Activate the emergency response system. D. Report this finding promptly to the health care provider and remain with the client.

Report this finding promptly to the health care provider and remain with the client.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely 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 client will be monitored closely to detect malignant changes.

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A. The client's swallowing ability B. The client's ability to speak C. The client's management of secretions D. The client's airway patency

The clients ability to swallow

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include? A. Check the gastric residual volume every 4 hours. B. Hold the tube feeding if the gastric residual volume is greater than 200 mL. C. Position client flat in bed during feedings. D. Use client assessment findings to determine tolerance of feedings.

Use client assessment findings to determine tolerance of feedings.

A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend what action? 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 nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings. C. Place a mask over the client's nose. D. Wear personal protective equipment.

Wear personal protective equipment.