1
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.
The nurse is assessing the skin graft site of a client who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which result?
Healthy graft
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
Which is the primary symptom of achalasia?
Difficulty swallowing
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 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
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 patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease
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 term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?
Chancre
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
Catheter hub
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
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.
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
A client is receiving a continuous tube feeding through an open system. Which action(s) will the nurse take when caring for the tube feeding system?
Select all that apply.
-Change the tubing every 24 hours.
-Use a pump to control the formula rate.
-Flush the feeding tube with sterile water every 4 hours.
-Change the formula according to the manufacturer recommendations.
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 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 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
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?
Flush with 10 mL of water.
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."
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?
Hang a solution of dextrose 10% and water until the new solution is available.
Rebound hypoglycemia is a complication of parenteral nutrition caused by
feedings stopped too abruptly.
A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.
Daily weights
Calorie counts for oral nutrients
Intake and output monitoring