Med Surge Exam 2
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?
"It is a vent that prevents backflow of the secretions." Explanation: The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.
Which of the following is an age-related change of the gastrointestinal system?
A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.
The primary source of microorganisms for catheter-related infections include the skin and which of the following?
Catheter hub The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.
A physician plans to send a client home with supplies to complete a hemoccult test on all stools for 3 days. During the client education, the nurse informs the client to avoid which of the following medications while collecting stool for the test?
Fecal occult blood testing (FOBT) is one of the most commonly performed stool tests. FOBT can be done at the bedside, in the physician's office, or at home. The client is taught to avoid aspirin, red meats, nonsteroidal antiinflammatory agents, and horseradish for 72 hours prior to the examination. Advil is an anti-inflammatory drug and should be avoided with FOBT.
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to
Instruct the client to swish prescribed nystatin (Mycostatin) 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 anitfungal 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 patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply.
Liquid stool softener Sublingual nitroglycerin Explanation: Liquid medications do not require any special preparation for administration via a feeding tube. Buccal or sublingual tablets are administered as prescribed. They are absorbed through the mucosa of the cheek or under the tongue and thus would not be administered through the feeding tube. Enteric-coated aspirin and sustained-release antihypertensive could not be given as is through a feeding tube. A change in formulation would be needed. An acetaminophen tablet would need to be crushed and dissolved in water before being given.
The nurse is assessing a 50-year-old, dark-skinned African American man and has noted that he appears jaundice. Most likely, the nurse made this observation by assessing which part of his body?
Mucous membranes In very dark-skinned clients, inspect the hard palate, gums, conjunctiva, and surrounding tissues for discoloration.
Pt with GERD who responds to this type of drug validates the disease
Proton pump inhibitors
Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis Salivary stones are mainly formed of calcium phosphate
Dietary measures for GERD
chocolate, tea, cola, and ceffeine lower esophageal sphincter pressure --> increasing reflux
NG tubes
don't reposition - may cause bleeding, can irrigate with saline if ordered, suctioning should be applied continuously and do NOT clamp post op. . . bumbai accumulation and stress the suture line
The most common symptom of esophageal disease is
dysphagia This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on 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 on swallowing.
most common complication of a peptic ulcer
hemorrhage occurs in 28% - 59% of patients
common causes of gastritis
overuse of aspirin, irritating foods, and ingestion of strong acids
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
weakness, sweating, and hershey squirts 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 nurse is interviewing a patient to determine suitability for home parenteral nutrition. Which patient statement would alert the nurse to a potential problem?
"I have a telephone, but it has been shut off because my bill is overdue." Lack of access to a working telephone would be a concern because a telephone is necessary for contacting home health personnel, arranging for prompt delivery of supplies, and emergency purposes. Available family support, a willingness to learn, a desire for self-sufficiency, and a physical home environment with adequate storage for supplies and a lack of obstacles that might hinder the patient's mobility are important to the success of home parenteral nutrition.
The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?
"My doctor will be able to remove any polyps he finds." Explanation: With a computed tomography (CT) colonography, other procedures such as polyp removal or biopsy cannot be done. It requires the same preparation as a colonoscopy, but sedation is not required. In addition, there is less risk of bowel perforation.
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
4 Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.
A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.
42 The client's weight of 154 pounds is equal to 70 kg. The client is to receive 0.6 g of protein for each 1 kg of body weight. 0.6 g/kg x 70 kg = 42 grams.
Normal amount of drainage after radical next surgery
80 - 120 mL for the first 24 hours 120+ may indicate chyle fistula or hemmorhage
A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?
A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Abdominal distention Explanation: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
The nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome?
Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
An NG tube may be inserted by the medical team. Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent. The patient is given nothing by mouth, and IV fluids are administered.
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the NG tube. When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but she should check NG tube patency first to help relieve the client's discomfort.
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.
A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse
Consults with the physician about decreasing the feeding to half-strength The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution.
A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following would be least appropriate to use to unclog the tube?
Cranberry juice To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube.
The nurse on an evidence-based practice council is making recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which of the following situations?
Daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line's patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn in order to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued.
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 Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.
Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?
Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.
Rebound hypoglycemia is a complication of parenteral nutrition caused by which of the following?
Feedings stopped too abruptly Explanation: Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.
The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?
Fluid volume deficit Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.
The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is
Flush with 10 mL of water. Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.
Which of the following is a function of the stomach? Select all that apply.
Food storage Secretion of digestive fluids Propels partially digested food into small intestine Explanation: The stomach stores food during eating, secretes digestive fluids, and propels the partially digested foods into the small intestine. Secretion of digestive enzymes is completed by the pancreas. The liver secretes bile.
Postoperatively, a patient with a radical neck dissection should be placed in which position?
Fowlers The patient should be placed in the Fowler's position to facilitate 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 client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?
GERD Metoclorpramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
The nurse is assisting the physician with a colonoscopy for a patient with rectal bleeding. The physician requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?
Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.
Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:
Greater than 200 mL. Research demonstrates that residual volumes of less than 200 mL appear to be well tolerated without risk of aspiration.
A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:
High fasting blood glucose level An adverse reaction to tube feedings is an elevated blood glucose level. The physical assessment data and renal function and liver function studies are normal.
A nurse prepares a patient for insertion of a nasoenteric tube. The nurse should position the patient:
High fowlers The patient should sit upright with some type of protective bib-like barrier. Privacy and adequate light are necessary. The tip of the nose is tilted and the tube aligned to enter the nostril following the floor of the nose, not upward toward the nasal bridge.
One or two bowel sounds in 2 minutes would be documented as which of the following?
Hypoactive Explanation: Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when 5 or 6 sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.
A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is
Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nastogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea. Reference:
Which of the following terms describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?
Intrinsic factor Explanation: Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12 cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein.
The nurse is planning care for a patient with painful oral lesions. Which of the following should be included in the patient's diet?
Jello
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?
Keeping the client in a semi-Fowler's position at all times. With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.
Regarding oral cancer, the nurse provides health teaching to inform the patient that
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 patient may complain of tenderness, and difficulty with chewing, swallowing, or speaking 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.
appropriate diet for active upper GI bleed
NPO until shock and bleeding is controlled and then diet is gradually increased, starting with ice chips, then clear liquids. no skim milk because it increases gastric acid production which could prolong bleeding
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following:
No land line; cell phone available and taken by family member during working hours Explanation: A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
Non tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, and it allows the patient freedom of movement, and provides easy access to the dressing site. PICC lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices also used for long-term home IV therapy (eg, Port-A-Cath, Mediport, Hickman Port, P.A.S. Port).
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to
Notify the surgeon about the tube's removal. If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube.
Pyloric Obstruction/ Gastric Outlet Obstruction (GOO)
Occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasms, edema, or from scar tissue that forms when an ulcer alternately heals and breaks down. Client may have nausea, vomiting, constipation, epigastric fullness, anorexia, and later - weight loss
The nurse is assisting the physician with a gastric acid stimulation test for a patient. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?
Pentagastrin or histamine
Which of the following is an enzyme secreted by the gastric mucosa?
Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit the client to drink only clear liquids After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.
Tube feedings are given to a patient after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which of the following measures should the nurse include in the care plan to reduce the risk of aspiration?
Place patient in semi-Fowler's position during and 60 minutes after an intermittent feeding To minimize the risk of aspiration, it is important to place the patient in a semi-Fowler's position during and 60 minutes after an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.
The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?
Provide frequent mouth care. Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.
A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?
Pyloric sphincter The pyloric sphincter is the opening between the stomach and duodenum. The cardiac sphincter is the opening between the esophagus and the stomach. The hypopharyngeal sphincter or upper esophageal sphincter prevents food or fluids from re-entering the pharynx. The ileocecal valve is located at the distal end of the small intestine and regulates flow of intestinal contents into the large intestine.
A nurse is preparing a presentation for a local community group for older adults on nutrition and anorexia in this population. Which of the following would the nurse include in the presentation as a possible contributing factor for anorexia in the older adult?
Reduction in and atrophy of taste buds Explanation: With age, the salivary glands become less active and the numbers of taste buds are reduced, contributing to anorexia in the older adult. Anorexia and weight loss in the older adult can also result from ill-fitting dentures or dysphagia (caused by oropharyngeal dysphagia), or may be a manifestation of depression. Decreased appetite may result from diminished oxygenation to the appetite centers in the brain caused by atherosclerosis or decreased cardiac stroke volume.
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
Remove the dressing, clean the site, and apply a new dressing. Explanation: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.
The nurse is conducting education relating to test preparation for a patient scheduled to undergo an abdominal ultrasonography. The nurse instructs the patient to do which of the following?
Restrict eating of solid food for 8 to 12 hours before the test. Explanation: For a patient who is scheduled to undergo an abdominal ultrasonography, the patient should restrict him- or herself from solid food for 6 to 8 hours to avoid having images of the test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.
A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?
Review the instructions with the person accompanying the client home. Explanation: A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and his memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions to the person who is accompanying the client home. It isn't appropriate for the nurse to tell the client to call back in the morning for instructions. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician.
A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse's suspicions? Select all that apply.
Shakiness Tachycardia Weakness Confusion Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate.
The patient is on a continuous tube feeding. The tube placement should be checked every
Shift Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.
A client is preparing for discharge to home, following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?
Slows gastric emptying Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.
Parotitis is a bacterial infection usually caused by
Staph Aureus
A nurse is doing a physical assessment on a client with a GI disorder. She is about to assess the client's abdomen. Which position will the nurse most likely ask the client to assume when performing this examination?
Supine with knees flexed slightly This position assists in relaxing the abdominal muscles. Client should lie in a supine position with knees flexed slightly to assist in relaxing the abdominal muscles.
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. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge.
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:
The nurse should instruct the graduate nurse to change the central venous catheter dressing every 48 hours or when the dressing becomes damaged or soiled.
Which of the following is one of the first clinical manifestations of esophageal cancer?
The patient first becomes aware of intermittent and increasing difficulty in swallowing. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. (Progress weight loss) Other clinical manifestations may include sensation of a mass in the throat, foul breath, and hiccups.
The nurse is teaching an unlicensed caregiver about bathing patients who are receiving tube feedings. Which of the following is the most significant complication related to continuous tube feedings?
The potential for aspiration Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?
The ultrasonography should be scheduled before the GI procedure. Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.
The nurse is monitoring a patient with nasoenteric intubation. The nurse contacts the physician when which of the following is noted?
Urinary output 20 mL/hr The nurse should notify the physician when the patient has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, BP of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit.
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
Vagus
The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse
Verifies location with an abdominal x-ray Initially, an x-ray should be used to confirm placement of the nasoduodenal tube. It is the most accurate method to verify tube placement. Adding 8 to 10 inches to the length of the tube after measuring from nose to earlobe to xiphoid process is not supported, because it does not indicate that the tube will be in the correct position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may be present. The traditional method of injecting air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflation is also an unreliable indicator.
Age-related change of the GI system
Weakened gag reflex, decreased motility, atrophy of the small intestine, and decreased mucus secretions
Initially, which diagnostic should be completed following placement of a NG tube?
X-ray Explanation: Initially an X-ray should be used to confirm tube placement. Subsequently, each time liquids or medications are administered, as well as once per shift for continuous feedings, a combination of three methods is recommended: measurement of tube length, visual assessment of aspirate, and pH measurement of aspirate.
Aphthous Stomatitis
a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks
Hairy leukoplakia
a condition often seen in HIV+ patients where white patches with rough hairlike projections occur, typically on the lateral border of the tongue
Actinic Cheilitis
an irritation of the lips associated with scaling, crusting, fissure; white overgrowth of horny layer of epidermis (hyperkeratosis)
Cancer of the esophagus
chronic irritation of the esophagus is a known risk factor
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:
diaphoresis, vomiting, and diarrhea. Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings. Reference:
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals. The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.
Vitamin B12 deficiency with chronic gastritis
injured gastric mucosa causes gastric atrophy and impaired parietal cells which lead to reduced absorption of intrinsic factor which is important in the absorption of vitamin B12--> pernicious anemia
duodenal ulcer
pain 2 - 3 hours after a meal and may experience weight gain
perforation of the peptic ulcer
sudden, severe upper abdominal pain(persisting and increasing in intensity) may be referred to the shoulders, especially the right shoulder because of irritation of the phrenic nerve in the diaphgram; vomiting, collapse, extremely tender and rigid abdomen, hypotension and tachycardia indicate shocl
BMI formula
weight / ht (inches^2) x 703
