MedSurg Ch 39 Management of Patients with Oral and Esophageal Disorders PrepU

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 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.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? Instruct the client to swish prescribed nystatin solution for 1 minute. Remove the plaque from the mouth by rubbing with gauze. Provide saline rinses prior to meals. Encourage the client to ingest a soft or bland diet.

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

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? Helping the client cope with body image changes Ensuring adequate nutrition Maintaining a patent airway Preventing injury

Maintaining a patent airway Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? 15 minutes 30 minutes 60 minutes 80 minutes

30 minutes Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? 30 minutes 1 hour 90 minutes 2 hours

1 hour The semi-Fowler position is necessary for a nasogastric (NG) feeding, with the client's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? 5-mL 10-mL 20-mL 30-mL

30-mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician? 150 mL 175 mL 200 mL 225 mL

225 mL If a residual volume greater than 200 mL is obtained twice, the nurse would need to notify the physician. A single residual volume of 200 mL or more does not indicate a need to withhold a feeding. Feedings may be continued in patients as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient's physical status.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? 20 to 40 mL 50 to 75 mL 80 to 120 mL 160 to 200 mL

80 to 120 mL

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

Bradycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding? Parotitis Sialadenitis Stomatitis Pyosis

Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

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

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

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: a. H2-receptor antagonists. b. Antispasmodics c. Proton pump inhibitors. d. Antacids

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

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? a. Hiatal hernia b. Gastroesophageal reflux disease c. Gastritis d. Esophageal tumor

d. Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

The nurse 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? a. Document the presence of stridor b. Administer a breathing treatment c. Notify the physician d. Lower the head of the bed

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

Which of the following is the most common type of diverticulum? a. Zenker's diverticulum b. Mid-esophageal c. Epiphrenic d. Intramural

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

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

b. Lithotripsy Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? a. Remove the tape from the nose of the client. b. Withdraw the tube gently for 6 to 8 inches. c. Provide oral hygiene. d. Flush with 10 mL of water.

d. 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.

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? a. Salem sump tube b. Miller-Abbott tube c. Sengstaken-Blakemore tube d. Levin tube

d. Levin tube 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.

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

d. Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? a. continuous feedings b. intermittent feeding c. bolus feeding d. cyclic feeding

a. continuous feedings Continuous feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, and cyclic feedings are not advised.

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis? Methicillin-resistant Streptococcus aureus (MRSA) Pneumococcus Staphylococcus aureus Streptococcus viridans

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

A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action? a. Assess the client's appetite. b. Assist the client into a supine position. c. Apply topical anesthetic to the client's nares as prescribed. d. Explain the process clearly to the client.

d. Explain the process clearly to the client. The process should be explained to the client before removal. A client should not normally be supine with an NG tube in place and anesthetic is not normally prescribed. Removal is not contingent on the client's appetite.

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? a. Aphthous stomatitis b. Nicotine stomatitis c. Erythroplakia d. Hairy leukoplakia

d. Hairy leukoplakia Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.

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? a. "It is a vent that prevents backflow of the secretions." b. "It acts as a siphon, pulling secretions into the clear tubing." c. "It helps regulate the pressure on the suction machine." d. "It works as a marker to make sure that the tube stays in place."

a. "It is a vent that prevents backflow of the secretions." 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 term describes an inflammation of the salivary glands? z. Parotitis b. Sialadenitis c. Stomatitis d. Pyosis

b. Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing a. pyrosis. b. dyspepsia. c. dysphagia. d. odynophagia.

a. pyrosis. Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.

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

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

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

Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action: a. Cleanses the insertion site with a chlorhexidine solution b. Uses a circular motion from insertion site outward c. Wipes catheter ports from distal end to insertion site d. Contaminates gloves and obtains a pair of sterile gloves for use

c. Wipes catheter ports from distal end to insertion site Proper cleansing of a CVAD includes cleaning the insertion site with a chlorhexidine solution in a circular motion from insertion site outward. The nurse will obtain another pair of sterile gloves to perform the procedure if contamination of gloves occurs. The nurse cleanses from insertion site outward to distal catheter ports.

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

c. Chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. Avoid beer, especially in the evening. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.

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

Cancer of the esophagus is most often diagnosed by which of the following? Esophagogastroduodenoscopy (EGD) with biopsy and brushings X-ray Barium swallow Fluoroscopy

Esophagogastroduodenoscopy (EGD) with biopsy and brushings Currently, diagnosis is confirmed most often by EGD with biopsy and brushings. The biopsy can be used to determine the presence of disease and cell differentiation. X-ray, barium swallow, and fluoroscopy are used in the diagnosis of hiatal hernia.

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? Discard the residual volume. Stop the continuous feeding. Decrease the rate to 40 mL/h. Notify the healthcare provider.

Notify the healthcare provider. 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.

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location? a. Tip of patient's nose b. Tragus of the ear c. Base of the neck d. Tip of the xiphoid process

a. Tip of patient's nose To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process.

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate? a. Achalasia b. Diffuse spasm c. Gastroesophageal reflex disease d. Hiatal hernia

a. Achalasia Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of a. organic fruit juice. b. roasted nuts. c. red meat that is high in fat. d. cheddar cheese.

a. organic fruit juice. Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Clients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.

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

b. Assess the graft for color and temperature. Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? a. Call the physician. b. Apply a dry sterile dressing to the site. c. Clamp the catheter. d. Tell the client to take and hold a deep breath.

c. Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

The most significant complication related to continuous tube feedings is a. the interruption of GI integrity. b. a disturbance of intestinal and hepatic metabolism. c. the increased potential for aspiration. d. an interruption in fat metabolism and lipoprotein synthesis.

c. the increased potential for aspiration. 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.

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? a. Metoclopramide (Reglan) b. Famotidine (Pepcid) c. Nizatidine (Axid) d. Esomeprazole (Nexium)

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

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

a. Place the client in the Fowler's position. All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.

A 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? a. 4 p.m. to 6 p.m. b. 6 p.m. to 8 p.m. c. 8 p.m. to 10 p.m. d. 10 p.m. to 12 a.m.

b. 6 p.m. to 8 p.m. 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.

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse a. Immediately starts the prescribed tube feeding b. Administers an initial bolus of 50 mL water c. Maintains a gauze dressing over the site for 3 days d. Pushes the stabilizing disk firmly against the skin

b. Administers an initial bolus of 50 mL water The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown.

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? a. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. b. Keep the vent lumen above the patient's waist to prevent gastric content reflux. c. Irrigate only through the vent lumen. d. Tape the tube to the head of the bed to avoid dislodgement.

b. Keep the vent lumen above the patient's waist to prevent gastric content reflux. 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 has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? a. Use a hard-bristled toothbrush. b. Rinse with an alcohol-based solution. c. Brush and floss daily. d. Continue with the usual diet.

c. Brush and floss daily. The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? a. Diverticulosis b. Paralytic ileus c. Dumping syndrome d. Small bowel obstruction

c. Dumping syndrome 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. The client may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, which indicates dumping syndrome. The client's symptoms are not caused by a diverticulosis, paralytic ileus, or a small bowel obstruction.

A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is most appropriate? a. Stop the tube feed and aspirate stomach contents. b. Increase the hourly feed rate so it finishes earlier. c. Keep the client in semi-Fowler position for 1 hour after feedings d. Administer fluid replacement by IV.

c. Keep the client in semi-Fowler position for 1 hour after feedings To minimize dumping syndrome, the client should remain in semi-Fowler position for 1 hour after the feeding. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? a. A length of 50 cm (20 in) b. A point that equals the distance from the nose to the xiphoid process c. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process d. The distance determined by measuring from the tragus of the ear to the xiphoid process

c. The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

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? a. Administer the feeding at a warm temperature to decrease peristalsis. b. Administer the feeding by bolus to prevent continuous intestinal distention. c. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. d. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.

d. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. 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.

Which of the following are functions of saliva? Select all that apply. a. Lubrication b. Protection against harmful bacteria c. Digestion d. Elimination e. Metabolism

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

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? a. Palpate the client's parotid glands to detect swelling and tenderness. b. Assess the temporomandibular joint for evidence of a malocclusion. c. Test the integrity of cranial nerve XII by asking the client to protrude the tongue. d. Inspect the client's gums for bleeding and hyperpigmentation.

a. Palpate the client's parotid glands to detect swelling and tenderness. 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.

A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care? a. Risk for Aspiration Related to Inhalation of Gastric Contents b. Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption c. Risk for Decreased Cardiac Output Related to Vasovagal Response d. Risk for Impaired Verbal Communication Related to Oral Trauma

a. Risk for Aspiration Related to Inhalation of Gastric Contents Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the client's nutritional status and does not affect cardiac output or communication.

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply. a. Weigh the client every day. b. Check blood glucose level every 6 hours. c. Cover insertion site with a transparent dressing that is changed daily. d. Use clean technique for all catheter dressing changes. e. Document intake and output.

a. Weigh the client every day. b. Check blood glucose level every 6 hours. e. Document intake and output. When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.

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? a. Emotional support from visitors and staff b. An effective means of communicating with the nurse c. Referral to a speech therapist d. Dietary teaching focused on consistency of food and frequency of feedings

b. An effective means of communicating with the nurse 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 nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a. Apply water-based lubricant to the nares daily. b. Auscultate lung sounds every 4 hours. c. Inspect the nose daily for skin irritation. d. Change the nasal tape every 2 to 3 days.

b. Auscultate lung sounds every 4 hours. 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 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. a. Assess for patency of the peripheral intravenous site b. Ensure availability of an infusion pump c. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel d. Administer the intravenous antibiotic in the same tubing as the parenteral nutrition e. Place a 1.5-micron filter on the tubing

b. Ensure availability of an infusion pump c. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel e. Place a 1.5-micron filter on the tubing 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.

A nurse is providing care for a client with a diagnosis of late-stage Alzheimer disease. The client has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? a. Frequent assessment of the client's abdominal girth b. Assessment for hemorrhage from the nasal insertion site c. Frequent lung auscultation d. Vigilant monitoring of the frequency and character of bowel movements

c. Frequent lung auscultation Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the client's cognitive deficits. Consequently, the nurse should auscultate the client's lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the client's abdominal girth is not a main focus of assessment.

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 a. Coiling in the client's mouth b. Irritating the epiglottis c. Inserted into the lungs d. Passing into the esophagus

c. Inserted into the lungs 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 nasogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: a. place the client in a supine position and prepare to perform cardiopulmonary resuscitation. b. place the client in high-Fowler's position and administer supplemental oxygen. c. turn the client on his left side and place the bed in Trendelenburg's position. d. position the client in the shock position with his legs elevated.

c. turn the client on his left side and place the bed in Trendelenburg's position. A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n) lichen planus. actinic cheilitis. chancre. leukoplakia.

chancre. A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus are white papules 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.

The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? a. History of diverticulitis b. Treatment for internal hemorrhoids c. Polyps removed during a colonoscopy d. Diagnosed with malabsorption syndrome

d. Diagnosed with malabsorption syndrome Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? a. Assess lung sounds bilaterally. b. Administer prescribed morphine intravenously. c. Obtain consent for the esophagogastroscopy. d. Suction the oral cavity of the client.

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

The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings? a. Aphthous stomatitis b. Kaposi's sarcoma c. Chancre d. Hairy leukoplakia

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

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

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

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply): a. Compares exposed tube length with original measurement b. Visually assesses the color of the aspirate c. Checks the pH of the gastric contents d. Confirms the tip of the tube with radiology e. Inserts 30 mL of tap water through the nasogastric tube

a. Compares exposed tube length with original measurement b. Visually assesses the color of the aspirate c. Checks the pH of the gastric contents The nasogastric tube must be checked every shift for placement when a client is receiving continuous feedings. Recommended methods are comparing the exposed nasogastric tube length to the original measurement, visually assessing the color of the aspirate, and checking the pH of the gastric contents with a pH sensor. Confirming tube placement with radiology is costly and may be performed at the time of initial insertion. Inserting tap water through the nasogastric tube does not verify placement.

A client's new onset of dysphagia has required insertion of an NG tube for feeding. What intervention should the nurse include in the client's plan of care? a. Confirm placement of the tube prior to each scheduled feeding. b. Have the client sip cool water to stimulate saliva production. c. Keep the client in a low Fowler position when at rest. d. Connect the tube to continuous wall suction when not in use.

a. Confirm placement of the tube prior to each scheduled feeding. Each time feedings are given, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the client should be positioned in a Fowler position. Oral fluid administration is contraindicated by the client's dysphagia.

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? a. Exhibiting hemoglobin A1C 8.2 b. Drinking fluoridated water c. Eating fruits and cheese in diet d. Using a soft-bristled toothbrush

a. Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: a. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. b. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. c. Feedings can be administered with the patient in the recumbent position. d. The patient cannot experience the deprivational stress of not swallowing.

a. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. 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 is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? a. Increasing difficulty in swallowing b. Sensation of a mass in throat c. Foul breath d. Hiccups

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

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? a. diaphoresis, vomiting, and diarrhea. b. manifestations of electrolyte disturbances. c. manifestations of hypoglycemia. d. constipation, dehydration, and hypercapnia.

a. diaphoresis, vomiting, and diarrhea. 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.

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? a. Administer antibiotics via the tube as prescribed. b. Wash the area around the tube with soap and water daily. c. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. d. Irrigate the skin surrounding the insertion site with normal saline before each use.

b. Wash the area around the tube with soap and water daily. Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not given to prevent site infection.

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? a. Ineffective Tissue Perfusion b. Impaired Skin Integrity c. Aspiration d. Imbalanced Nutrition: Less Than Body Requirements

d. Imbalanced Nutrition: Less Than Body Requirements 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. Aspiration is not a likely consequence of dental caries.

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? a. Aspirating for residual contents every 4 to 8 hours. b. Administering 15 to 30 mL of water every 4 hours. c. Giving the feedings at room temperature. d. Keeping the client in a semi-Fowler's position at all times.

d. 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.