PREPU CH 39

The nurse's comprehensive assessment of a client includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

Presence of a painless sore with raised edges

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.

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):

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

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?

Provide the client with an irrigating solution of baking soda and warm water.

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.

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?

Risk for Aspiration Related to Inhalation of Gastric Contents

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

1 hour

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?

225 mL

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260

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?

30-mL

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?

6

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?

6 p.m. to 8 p.m.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80 to 120 mL

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

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."

The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state

"Many oral cancers produce no symptoms in the early stages."

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?

Excess fluid volume

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?

Achalasia

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.

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse

Administers an initial bolus of 50 mL water

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

A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage?

Approximately 80 to 120 mL

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assessing lung sounds

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse?

Attaches the fat emulsion tubing to a Y connector close to the infusion site

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?

Boerhaave syndrome

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre

The nurse is caring for a group of clients. Which client(s) would be a candidate for total parenteral nutrition (TPN)? Select all that apply.

Child with short bowel syndrome Middle-aged man with acute pancreatitis Man with two-thirds of his colon removed

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter.

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):

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents

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?

Confirm placement of the tube prior to each scheduled feeding.

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

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?

Explain the process clearly to the client.

Postoperatively, a client with a radical neck dissection should be placed in which position?

Fowler

The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse?

Infuse a solution containing 10% dextrose and water.

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

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.

Instruct the client to eat slowly and chew the food thoroughly. Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products.

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.

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.

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

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

Lithotripsy

Immediate medical and nursing management is necessary for a patient who has ingested a corrosive substance and experienced a chemical burn. Select the first response.

Maintain a patent airway.

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.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?

Uncontrolled rhythmic movements of the face or limbs

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?

Wash the area around the tube with soap and water daily.

Which of the following is the most common type of diverticulum?

Zenker's diverticulum

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?

diaphoresis, vomiting, and diarrhea.

The most common symptom of esophageal disease is

dysphagia

The nurse provides health teaching to inform the client with oral cancer that

many oral cancers produce no symptoms in the early stages.

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

organic fruit juice.

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the

potential risk for aspiration.

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift.

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

Which clinical manifestation is not associated with hemorrhage?

Bradycardia

Which is the primary symptom of achalasia?

Difficulty swallowing

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?

Gastroesophageal reflux disease

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?

Imbalanced Nutrition: Less Than Body Requirements

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

When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention?

Elevate the head of the bed 90 degrees during meals.

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.

Elevate the upper body on pillows. Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks.

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level

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.

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?

Hairy leukoplakia

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?

Maintaining a patent airway

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 would make a recommendation when noticing which circumstance?

No land line; cell phone available and taken by family member during working hours

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

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.

Tachycardia Diaphoresis Diarrhea

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.

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?

Cranberry juice

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?

Diagnosed with malabsorption syndrome

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

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

Dysphagia

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?

Ensure that none of the client's visitors have an infection.

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

Parotid

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Place the client in the Fowler's position.

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action?

Report possible signs of aspiration pneumonia to the primary provider.

A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times?

Semi-Fowler's with the head of the bed elevated 30 to 45 degrees

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

Sialolithiasis

The nurse reviews data collected during a client assessment. Which lifestyle modifications will the nurse discuss with the client to prevent the development of gastroesophageal reflux disease (GERD)? Select all that apply.

Smoking cessation Avoid eating before bedtime Limit the intake of alcohol Achieve a BMI of 22

An older client is diagnosed with parotitis. What bacterial infection does the nurse suspect caused the client's parotitis?

Staphylococcus aureus

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

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed?

When the residual is greater than 200 mL

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease, it is usual to have:

no symptoms.

A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about?

Extrapyramidal

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?

Take long, slow breaths

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation.

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: Fasting Glucose: 168 mg/gL BUN: 12 mg/dL Creatine: 1.0 mg/dL AST: 28 units ASL: 24 units GGPT: 10 IU/L LDH: 136 units

Fasting blood glucose level

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

High epigastric pain and/or discomfort

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

Stridor

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Metoclopramide (Reglan)

Which term describes an inflammation of the salivary glands?

Sialadenitis