Med surge prepU 39: Oral and Esophageal Disorders
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?
10 to 15 minutes Explanation: Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.
The nurse is preparing to administer orlistat to a client with obesity. Which safety warning(s) should the nurse consider when administering this medication to the client? Select all that apply. 1Administer with meals, stagger administration with other drugs. 2Provide a vitamin supplement with the medication. 3Monitor liver function. 4Avoid caffeine. 5Avoid use among clients with heart disease, hypertension, and hyperthyroidism.
123 The safety warnings that the nurse should consider include administering orlistat with meals and staggering administration with other drugs, the requirement of vitamin supplementation due to nonabsorption of nutrients, and monitoring liver function. Avoiding caffeine and avoiding the use of the medication among clients with heart disease, hypertension, and hyperthyroidism are applicable to appetite suppressants such as benzphetamine, diethylpropion, phendimetrazine, and phentermine, not orlistat.
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. 1Assess for patency of the peripheral intravenous site 2Ensure availability of an infusion pump 3Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel 4Administer the intravenous antibiotic in the same tubing as the parenteral nutrition 5Place a 1.5-micron filter on the tubing
235 Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for the administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatibilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.
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 Explanation: 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.
The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? 1 , 4, 6, 8
6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?
A canker sore of the oral soft tissues Explanation: Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? Digestive enzyme mixed with warm water Air insufflation Cranberry juice Commercial enzyme product
Cranberry juice Explanation: 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 is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome?
Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: 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. Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, not at a warm temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated), rather than by bolus, to prevent sudden distention of the intestine. Instill the minimal amount of water needed to flush the tubing before and after a feeding, not to dilute the formula but because fluid given with a feeding increases intestinal transit time.
A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time?
An effective means of communicating with the nurse Explanation: Verbal communication may be impaired by radical surgery for oral cancer. Emotional support and dietary teaching are critical aspects of the plan of care; however, the client's ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the client's rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care
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?
Assess the graft for color and temperature. Explanation: 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 with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by Providing fluids to drink Assessing lung sounds Administering the prescribed analgesic Preparing for a barium swallow
Assessing lung sounds Explanation: 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.
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?
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 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? Periapical abscess Halitosis Zenker diverticulum Boerhaave syndrome
Boerhaave syndrome Explanation: 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.
Which clinical manifestation is not associated with hemorrhage? Tachycardia Tachypnea Bradycardia Hypotension
Bradycardia Explanation: 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.
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? Leukoplakia Chancre Actinic cheilitis Lichen planus
Chancre Explanation: 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.
Which is the primary symptom of achalasia? Chest pain Difficulty swallowing Pulmonary symptoms Heartburn
Difficulty swallowing Explanation: 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.
A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?
Dumping syndrome Explanation: Osmolality is an important consideration for clients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment
An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom? Hiatal hernia Gastroesophageal reflux disease Gastritis Esophageal tumor
Esophageal tumor Explanation: 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.
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 Explanation: 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,
A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about? Peptic ulcer disease or Extrapyramidal
Extrapyramidal Explanation: 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.
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 Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastritis Gastroesophageal reflux disease Peptic ulcer with melena Diverticulitis with perforation
Gastroesophageal reflux disease Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Feedings can be administered with the patient in the recumbent position. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. The patient cannot experience the deprivational stress of not swallowing.
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.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?
Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.
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 Hairy leukoplakia Nicotine stomatitis Erythroplakia
Hairy leukoplakia Explanation: 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.
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Have someone go to the pharmacy to obtain the new solution. Slow the current infusion rate so that it will last until the new solution arrives. Begin an infusion of normal saline in another site to maintain hydration. Hang a solution of dextrose 10% and water until the new solution is available.
Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.
A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? Ineffective Tissue Perfusion Impaired Skin Integrity Imbalanced Nutrition: Less Than Body Requirements Aspiration
Imbalanced Nutrition: Less Than Body Requirements Explanation: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a person's nutritional status. Dental caries do not typically affect the client's tissue perfusion or skin integrity
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?
Increasing difficulty in swallowing Explanation: 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.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as
Ineffective airway clearance related to obstruction by mucus Explanation: All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Irrigate only through the vent lumen. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Tape the tube to the head of the bed to avoid dislodgement. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg.
Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.
The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?
Levin tube Explanation: A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengstaken-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube.
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? Biopsy Chemotherapy Radiation Lithotripsy
Lithotripsy Explanation: 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.
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. Encourage the client to position himself on his side. Provide oxygen without humidity through the tracheostomy tube.
Make a notation on the call light system that the client cannot speak.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
Metoclopramide (Reglan) Explanation: 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.
A client is receiving continuous tube feedings at 75 mL/h. When the nurse checked the residual volume 4 hours ago, it was 250 mL, and now the residual volume is 325 mL. What is the priority action by the nurse? Decrease the rate to 40 mL/h. Notify the healthcare provider. Stop the continuous feeding. Discard the residual volume.
Notify the healthcare provider. Explanation: The second residual volume is greater than the first. When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, the nurse notifies the healthcare provider. The nurse does not discard the aspirate because the client has partially digested this fluid. After discussing with the healthcare provider, the nurse may stop the continuous feeding for some time or decrease the rate of infusion, but stopping the tube feeding is not an independent nursing action.
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?
Notify the physician Explanation: 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.
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? -Lower the head of the bed -Document the presence of stridor -Administer a breathing treatment -Notify the physician
Notify the physician Explanation: 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 Acyclovir Fluocinolone acetonide oral base gel
Nystatin Explanation: 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.
An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
Palpate the client's parotid glands to detect swelling and tenderness. Explanation: Older adults and debilitated clients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system.
An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
Palpate the client's parotid glands to detect swelling and tenderness. Explanation: Older adults and debilitated clients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.
The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse?
Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Explanation: Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.
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: -Proton pump inhibitors. -H2-receptor antagonists. -Antispasmodics -Antacids
Proton pump inhibitors. Explanation: 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): Twisting of the duodenum through an opening in the diaphragm. Protrusion of the upper stomach into the lower portion of the thorax. 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. Explanation: 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.
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. 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.
Provide the client with an irrigating solution of baking soda and warm water. Explanation: 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.
When a central venous catheter dressing becomes moist or loose, what should a nurse do first? Draw a circle around the moist spot and note the date and time. Notify the physician. Remove the catheter, check for catheter integrity, and send the tip for culture. Remove the dressing, clean the site, and apply a new dressing.
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
A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan?
Risk for Impaired Skin Integrity Related to the Presence of NG Tube Explanation: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This client's NG tube is in place for decompression, so complications of enteral feeding do not apply.
A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan? Risk for Unstable Blood Glucose Related to Enteral Feedings Risk for Impaired Verbal Communication Related to Presence of NG Tube Risk for Excess Fluid Volume Related to Enteral Feedings Risk for Impaired Skin Integrity Related to the Presence of NG Tube
Risk for Impaired Skin Integrity Related to the Presence of NG Tube Explanation: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This client's NG tube is in place for decompression, so complications of enteral feeding do not apply.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis Explanation: 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.
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 Pant like a dog Bear down as if having a bowel movement Take long, slow breaths
Take long, slow breaths Explanation: During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge.
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. Explanation: 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. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? Dry mouth not relieved by sugar-free hard candy Hyperactivity Anxiety or irritability Uncontrolled rhythmic movements of the face or limbs
Uncontrolled rhythmic movements of the face or limbs Explanation: 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.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? -Weakness, diaphoresis, diarrhea 90 minutes after eating -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 Explanation: 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.
The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? When the residual is about 50 mL When the residual is greater than 200 mL When the residual is between 50 and 80 mL When the residual is about 100 mL
When the residual is greater than 200 mL Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.
Which of the following is the most common type of diverticulum?
Zenker's diverticulum Explanation: 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 client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? -constipation, dehydration, and hypercapnia. -diaphoresis, vomiting, and diarrhea. -manifestations of hypoglycemia. -manifestations of electrolyte disturbances.
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.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?
metoclopramide Explanation: 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.
A client has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. What is the nurse's best response to this change in health status? Prepare to administer chemotherapeutics as prescribed. Arrange for a diet that is high in protein and low in fat. Ensure that none of the client's visitors have an infection. Administer colony stimulating factors (CSFs) as prescribed.
nsure that none of the client's visitors have an infection. Explanation: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the client's immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? 8 p.m. to 10 p.m. 10 p.m. to 12 a.m. 6 p.m. to 8 p.m. 4 p.m. to 6 p.m.
p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.
The most significant complication related to continuous tube feedings is -a disturbance of intestinal and hepatic metabolism. -the increased potential for aspiration. -the interruption of GI integrity. -an interruption in fat metabolism and lipoprotein synthesis.
the increased 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 client 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 who had oral cancer has had extensive surgery to excise the malignancy. Although surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to this client and family?
time to mourn, accept, and adjust to the loss Explanation: The first time family members or clients see the effects of surgery, the experience usually is traumatic. The nurse needs to promote effective coping and therapeutic grieving at this time. Responses may range from crying or extreme sadness and avoiding contact with others to refusing to talk about the surgery or changes in appearance. Allowing the client time to mourn, accept, and adjust to losses is essential.
