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Airway and breathing are priorities according to Maslow's hierarchy of needs.
True
What should the client be before a procedure requiring the gag reflex to return?
NPO
What could pain after a procedure indicate?
Perforation
Which intervention is appropriate for a client making a coarse, high-pitched sound upon inspiration after a radical neck dissection?
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What is the nurse's best initial action before removing a client's NG tube?
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Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted, and is a primary lesion of syphilis?
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What should the first activity performed by the nurse be for a client with a suspected foreign body obstruction?
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For which reason will the nurse question the use of a standard polymeric formula for enteral nutrition?
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What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours post neck dissection?
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What is the client's priority need after a hemiglossectomy with stable vital signs and a patent airway?
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What intervention is most appropriate for a client experiencing dumping syndrome due to tube feedings?
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Which option should the school nurse caution children against consuming to reduce tooth decay?
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What type of lesions should the nurse document for a client with HIV exhibiting white patches on the tongue?
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What does the nurse explain a hernia is?
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The blue vent lumen of the Salem sump tube should be kept above the patient's waist to prevent reflux.
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What should the nurse prioritize when caring for a nonresponsive client with a nasogastric tube due to gastrointestinal bleeding?
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What motility disorder does food feeling 'sticking' in the esophagus indicate?
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What size syringe should be used to irrigate a small bore feeding tube?
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What intervention is most important for a client following a graft reconstruction of the neck?
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What intervention should the nurse include for a client with an NG tube due to dysphagia?
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What is the nurse's priority action after a radical neck dissection when anesthesia has worn off?
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What assessment places an elderly client at risk for dental caries?
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Which of the following is the most common type of diverticulum?
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Which condition is most consistent with the findings of a shallow ulcer with a yellow center and red border in an HIV positive client?
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When preparing to insert a nasogastric tube, the nurse places the distal tip of the tube at which location?
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Which term describes an inflammation of the salivary glands?
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What type of nasogastric tube is used for single lumen insertion?
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Which medication accelerates gastric emptying in the treatment of GERD?
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The nurse would plan to irrigate a feeding tube again at which time after the last irrigation at 2 p.m.?
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Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?
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What is the most appropriate intervention for a postoperative client at risk for infection related to the presence of a wound and tube?
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A nurse should identify what risk diagnosis for a client with achalasia?
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What actions are a priority for the nurse to perform prior to administration of a 25% dextrose solution of parenteral nutrition?
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Which of the following are functions of saliva?
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What nursing measure is appropriate to prevent or minimize dumping syndrome for a patient receiving high-carbohydrate tube feeding?
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The nurse notes that a client has inflammation of the salivary glands. What finding should the nurse document?
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If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
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How long should the nurse administer a tube feeding via intermittent gravity drip?
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Which actions would the nurse perform while a client receives parenteral nutrition (PN)?
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What instruction should the nurse give to a client recovering from radiation therapy who has erythema, edema, and pain of the mouth?
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What instruction should the nurse provide to a client with a chancre on the lips?
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What should a nurse suspect if a client begins to cough constantly and has difficulty breathing during nasogastric tube insertion?
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What type of drug classification helps treat symptoms of gastroesophageal reflux disease (GERD)?
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Which of the following is a proton pump inhibitor used in the treatment of GERD?
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What should the nurse do to verify placement of a nasogastric tube every shift for a client receiving continuous tube feeding?
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What is the appropriate first step after a client has received percutaneous endoscopic gastrostomy (PEG) tube placement?
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What instructions should a nurse give to a patient with GERD to decrease lower esophageal sphincter pressure and irritation?
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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? (Select all that apply)
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When planning educational interventions for a client with a history of frequent, serious dental caries, the nurse should identify a risk for what nursing diagnosis?
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What is the first action the nurse should take when discontinuing a nasogastric tube that had been used for decompression?
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What action should be recommended for the graduate nurse when cleaning a central venous access device (CVAD) if they do the following incorrectly?
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What is the initial manifestation of esophageal cancer the nurse should assess?
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The most significant complication related to continuous tube feedings is:
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When a client with gastroesophageal reflux disease (GERD) reports a burning sensation in the esophagus, what term describes this symptom?
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In evaluating a client with late-stage Alzheimer disease who is starting supplemental feedings through an NG tube, which assessment addresses the most significant potential complication?
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For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?
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In an older adult client reporting general difficulty swallowing, which assessment finding is most significant?
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The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is:
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Cancer of the esophagus is most often diagnosed by which of the following?
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An older adult patient diagnosed with parotitis is suspected to be caused by which bacteria?
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For a client diagnosed with esophageal cancer who has difficulty swallowing, what should the nurse assign the highest priority?
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A client has a cheesy white plaque in the mouth that looks like milk curds and can be rubbed off. What is the nurse's best intervention?
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A client is receiving continuous tube feedings at 75 mL/h. The nurse checks the residual volume 4 hours ago, and it was 250 mL, but now it is 325 mL. What is the priority action by the nurse?
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A nurse suspects an air embolus after the insertion of a subclavian central line. What should she do?
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Which clinical manifestation is not associated with hemorrhage?
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When inserting a Levin tube for gastric decompression, it should be inserted to what length?
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Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:
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Which assessment finding would be most important for indicating dumping syndrome in a post-gastrectomy client?
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A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. What must the nurse remain alert for to monitor evidence of intolerance?
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After a client with achalasia underwent pneumatic dilation, what intervention should the nurse prioritize?
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Study Notes
Tube Feeding and Aspiration Risk
- To minimize aspiration risk during tube feedings, maintain the client in a semi-Fowler's position consistently.
- Regularly check for residual contents to ensure appropriate nutrition and prevent overfeeding.
Nutritional Implications of Dental Caries
- Frequent, severe dental caries can lead to imbalanced nutrition, as oral health is crucial for adequate nutrition.
Nasogastric Tube Removal Protocol
- Always flush a nasogastric tube with water before removal to clear debris and protect gastric tissue.
Central Venous Access Device (CVAD) Care
- Proper cleansing includes moving from the insertion site outward when cleaning catheter ports; contamination requires sterile gloves.
Esophageal Cancer Symptoms
- The primary symptom of esophageal cancer is increasing difficulty swallowing, which may progress as the tumor obstructs the esophagus.
Aspiration Risk with Continuous Tube Feedings
- Aspiration remains the most significant complication due to the bypass of normal swallowing mechanisms with tube feedings.
Pyrosis and GERD
- Pyrosis is a burning sensation in the esophagus, commonly linked with gastroesophageal reflux disease (GERD).
Aspiration Monitoring in Dementia Patients
- For clients with cognitive deficits, frequent lung auscultation and oxygen saturation monitoring are essential to prevent aspiration.
Treatment of Salivary Calculi
- Lithotripsy is the procedure that utilizes shock waves to break up salivary stones, often replacing the need for surgical removal.
Esophageal Tumors as a Significant Condition
- Difficulty swallowing in older adults often indicates serious conditions like esophageal tumors, necessitating urgent evaluation.
Chancre Lesion in Syphilis
- A chancre is characterized as a primary syphilitic lesion that starts as a reddened, ulcerated sore that crusts over.
Diagnosis of Esophageal Cancer
- Esophagogastroduodenoscopy (EGD) with biopsy is the preferred method for diagnosing esophageal cancer.
Parotitis in Older Adults
- Staphylococcus aureus is commonly the bacteria responsible for parotitis in older, dehydrated individuals.
Priority in Esophageal Cancer Care
- Maintaining a patent airway is paramount in clients with esophageal cancer, as tumor pressure can obstruct air passage.
Management of Oral Candidiasis
- Nystatin solution swished in the mouth is the best intervention for cheesy plaques indicative of oral candidiasis.
Residual Volume in Tube Feedings
- When residual volume exceeds 200 mL, notify the healthcare provider rather than discarding contents to monitor nutrition status.
Air Embolus Protocol
- Position clients suspected of having an air embolus on their left side in Trendelenburg’s position to prevent complications.
Clinical Assessment of Hemorrhage
- Bradycardia is not typically associated with hemorrhage; instead, tachycardia, tachypnea, and hypotension are indicators.
Levin Tube Insertion
- Insert the Levin tube to a length determined by measuring from the nose to earlobe, then to the xiphoid process plus an extra length.
Gastrostomy Feedings
- Preferred in comatose patients due to the intact gastroesophageal sphincter, reducing the risk of regurgitation and aspiration.
Dumping Syndrome Identification
- Symptoms of weakness, diaphoresis, and diarrhea occurring 90 minutes post-meal suggest dumping syndrome after gastric surgeries.
Monitoring for Feeding Intolerance
- Watch for signs like diaphoresis, vomiting, and diarrhea during enteral feedings to assess for intolerance.
Post-Pneumatic Dilation Care
- Post-procedure, assess lung sounds to rule out esophageal perforation, while monitoring for airway and breathing needs.
Stridor Post-Neck Dissection
- Report stridor immediately following radical neck dissection, as it signals potential airway obstruction.
NG Tube Removal Procedure
- Clearly explain the removal process to the patient prior to executing the withdrawal of the nasogastric tube.
Definition of Chancre
- A chancre is specifically described as a primary ulcerative lesion associated with syphilis.### Lichen Planus and Related Conditions
- Lichen planus appears as white papules formed at intersections of interlacing lesions.
- Actinic cheilitis is characterized by irritation of the lips, leading to scaling and crusting fissures.
- Leukoplakias present as white patches, typically located in the buccal mucosa.
Emergency Response to Foreign Body in Throat
- Prioritize assessing lung sounds bilaterally to check for pneumothorax risk.
- Little saliva indicates suctioning is unnecessary; consent for procedures is obtained after initial assessment.
- High respiratory rate and anxiety signal potential complications from esophageal obstruction.
Enteral Nutrition Considerations
- Standard polymeric formula suitable for clients with normal digestive function.
- Question use in clients with malabsorption syndrome due to undigested components.
Post-Neck Dissection Expectations
- Expect serosanguineous drainage of 80 to 120 mL within the first 24 hours following surgery.
- Effective communication is the priority for patients post-hemiglossectomy, facilitating safe care delivery.
Managing Complications from Tube Feedings
- Diarrhea may indicate dumping syndrome; maintain semi-Fowler position after feedings to minimize symptoms.
- Continuous feeding is the recommended approach for clients at risk for diarrhea from hypertonic solutions.
Dental Health Education for Children
- High sugar content in organic fruit juice increases risk of tooth decay.
- Alternative snacks like fruits, vegetables, nuts, and cheese are encouraged for dental health.
Recognizing Oral Lesions in HIV Positive Patients
- Hairy leukoplakia, marked by white patches on the tongue, is typically associated with HIV.
- Aphthous stomatitis presents as painful, shallow ulcers with a yellow center, common in those with HIV.
Understanding Hiatal Hernia
- A hiatal hernia involves the protrusion of the upper stomach into the thoracic cavity through the diaphragm.
Assessment Priorities in Elderly Patients
- Parotitis risk in elderly clients emphasizes the need for gland inspection and detection of tenderness.
Esophageal Motility Disorders
- Symptoms resembling food sticking in the esophagus suggest achalasia, characterized by ineffectual peristalsis and sphincter relaxation failure.
Nasogastric Tube Considerations
- Use a 30-mL syringe for irrigation to prevent tube rupture.
- Confirmation of nasogastric tube placement is essential before feedings.
Functionality of Gastric Tubes
- The blue vent lumen of a Salem sump tube should remain above the patient's waist to prevent reflux.
Postoperative Care Following Neck Surgery
- Prioritize placing the client in Fowler's position to improve respiratory function post-anesthesia.
Risk Factors for Dental Caries
- A hemoglobin A1C of 8.2 is a risk factor due to potential diabetes complications affecting oral health.
Types of Diverticulum
- Zenker's diverticulum is the most common type, significantly more frequent in men.
Oral Lesions Assessment in HIV Patients
- A shallow ulcer with a yellow center on the inner lip is indicative of aphthous stomatitis, not other lesions associated with HIV.
Insertion Technique for Nasogastric Tubes
- Measure the length to be inserted by placing the tube tip at the patient's nose, tragus of the ear, and down to the xiphoid process.
Salivary Gland Inflammation
- Sialadenitis refers to inflammation of the salivary glands, whereas parotitis specifically targets the parotid glands.
Types of Nasogastric Tubes
- Levin tube is a single lumen tube, while Salem sump is a double lumen.
Medications Affecting Gastric Emptying
- Metoclopramide (Reglan) is a prokinetic agent that accelerates gastric emptying, used in the treatment of GERD.### Feeding Tube Management
- Feeding tubes should be irrigated every 4 to 6 hours, with the next scheduled irrigation at 6 p.m. to 8 p.m.
- Maintain semi-Fowler position for at least 1 hour post-intermittent tube feeding to minimize reflux risk.
Postoperative Care
- For patients post-gastrostomy, daily cleaning of the area around the tube with soap and water is essential to prevent infection.
- Avoid using hydrogen peroxide or other substances that may irritate the skin around the tube.
Risk Assessments
- For clients diagnosed with achalasia, prioritize identifying the risk for aspiration due to the inhalation of gastric contents.
Parenteral Nutrition Protocols
- Prior to administering a 25% dextrose solution of parenteral nutrition, ensure the availability of an infusion pump, baseline CBC and chemistry monitoring, and use a 1.5-micron filter on the IV tubing.
Functions of Saliva
- Saliva serves three main functions: lubrication, protection against harmful bacteria, and aiding digestion.
Managing Dumping Syndrome
- To prevent dumping syndrome, administer feedings with the patient in a semi-Fowler's position. This helps reduce the effect of gravity and slows intestinal transit time.
Salivary Gland Inflammation
- Sialadenitis is the medical term for inflammation of the salivary glands, while parotitis is specific to inflammation of the parotid glands.
Emergency Procedures for Catheters
- If a central venous catheter disconnects, promptly clamp the catheter. Other actions can follow the initial response.
Administration of Tube Feedings
- Tube feedings using intermittent gravity drip should be administered over a minimum of 30 minutes.
Monitoring Nutrition in Parenteral Nutrition
- Daily weight checks, blood glucose monitoring every 6 hours, and documentation of intake and output are crucial during parenteral nutrition.
Oral Care after Radiation Therapy
- Patients undergoing radiation therapy timing experience sore mouths should maintain daily oral care, avoiding alcohol-based rinses and brushing with a soft-bristled toothbrush.
Instruction for Chancres
- Caution against spreading lesions like chancres is essential; advise cold soaks, good oral hygiene, and antibiotic administration.
Tube Insertion Complications
- Constant coughing and difficulty breathing during nasogastric tube insertion indicate potential lung insertion; immediate action is necessary.
Medications for GERD
- Proton pump inhibitors are effective for treating gastroesophageal reflux disease (GERD), outperforming H2-receptor antagonists for managing acid secretion.
Confirming NG Tube Placement
- Confirm NG tube placement through exposed tube length comparison, aspirate color assessment, and gastric content pH checks.
Post-PEG Tube Placement Care
- Initial fluid administration after PEG tube placement may include a bolus of 50 mL of water, transitioning to formula feeding by the following day.
Health Teaching for GERD Patients
- Patients should avoid beer in the evening, elevate the head of the bed, and refrain from eating or drinking two hours before bedtime to reduce GERD symptoms.
Monitoring Gastric Residual Volume
- A residual gastric volume greater than 200 mL recorded twice necessitates notifying the physician, as it indicates a potential issue with feeding tolerance.
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Description
Test your knowledge on the management of patients with oral and esophageal disorders. This quiz will cover key concepts related to tube feeding and measures to reduce aspiration risk. Perfect for nursing students preparing for exams!
