Ch. 54 Flashcards
A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective?
a.
“I can only take this medicine at night.”
b.
“I should take this on a full stomach.”
c.
“This drug decreases stomach acid.”
d.
“This should be taken 1 hour before meals.”
ANS: B
Gaviscon should be taken with food in the stomach. It can be taken with meals at any time. Its mechanism of action is not to decrease stomach acid.
DIF: Evaluating/Synthesis REF: 1113
A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first?
a.
Document the findings in the chart.
b.
Notify the surgeon immediately.
c.
Reassess the drainage in 1 hour.
d.
Take a full set of vital signs.
ANS: D
The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess.
DIF: Applying/Application REF: 1116
A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching?
a.
“After the operation I can eat anything I want.”
b.
“I will have to eat smaller, more frequent meals.”
c.
“I will take stool softeners for several weeks.”
d.
“This surgery may not totally control my symptoms.”
ANS: A
Nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. The other statements show good understanding.
DIF: Evaluating/Synthesis REF: 1117
A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met?
a.
Choosing foods that are easy to swallow
b.
Lungs clear after meals and snacks
c.
Properly performing swallowing exercises
d.
Weight unchanged after 2 weeks
ANS: B
All these assessment findings are positive for this client. However, this client is at high risk for aspiration. Clear lungs after eating indicates no aspiration has occurred. Choosing easy-to-swallow foods, performing swallowing checks, and having an unchanged weight do not assess aspiration, and therefore do not indicate that the priority goal has been met.
DIF: Evaluating/Synthesis REF: 118
A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client?
a.
Enteral tube feeding
b.
Esophageal dilation
c.
Nissen fundoplication
d.
Photodynamic therapy
ANS: B
Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer.
DIF: Understanding/Comprehension REF: 1120
A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best?
a.
Arrange an intensive care unit tour.
b.
Assess the client’s psychosocial status.
c.
Document the teaching and response.
d.
Have the client begin nutritional supplements.
ANS: B
Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the client’s psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope.
DIF: Applying/Application REF: 1120
A client is 1 day postoperative after having Zenker’s diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate?
a.
Document the findings as normal.
b.
Irrigate the NG tube with sterile saline.
c.
Notify the surgeon about this finding.
d.
Remove and reinsert the NG tube.
ANS: C
NG tubes placed during surgery should not be irrigated or moved unless prescribed by the surgeon. The nurse should notify the surgeon about this finding. Documentation is important, but this finding is not normal.
DIF: Applying/Application REF: 1123
A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the client’s neck. What action by the nurse takes priority?
a.
Assess the client’s oxygenation.
b.
Facilitate a STAT chest x-ray.
c.
Prepare for immediate surgery.
d.
Start two large-bore IVs.
ANS: A
The priorities of care are airway, breathing, and circulation. The priority option is to assess oxygenation. This occurs before diagnostic or therapeutic procedures. The client needs two large-bore IVs as a trauma client, but oxygenation comes first.
DIF: Applying/Application REF: 1123
A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene?
a.
Checking tube placement every 4 to 8 hours
b.
Monitoring and documenting drainage from the NG tube
c.
Pinning the tube to the gown so the client cannot turn the head
d.
Providing oral care every 4 to 8 hours
ANS: C
The client should be able to turn his or her head to prevent pulling the tube out with movement. The other actions are appropriate.
DIF: Applying/Application REF: 1123
A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first?
a.
Notify the surgeon.
b.
Put on a pair of gloves.
c.
Reinsert the NG tube.
d.
Take a set of vital signs.
ANS: B
To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking vital signs and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back to the operating room.
DIF: Applying/Application REF: 1114
A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client?
a.
Famotidine (Pepcid)
b.
Magnesium hydroxide (Maalox)
c.
Omeprazole (Prilosec)
d.
Ranitidine (Zantac)
ANS: C
Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.
DIF: Remembering/Knowledge REF: 1113
After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best?
a.
“Bacteria can often cause ulcers.”
b.
“This operation often causes ulcers.”
c.
“The medication keeps your blood pH low.”
d.
“It prevents stress-related ulcers.”
ANS: D
After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The other responses are incorrect.
DIF: Understanding/Comprehension REF: 1113
A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?
a.
Client who underwent diverticula removal with a pulse of 106/min
b.
Client who had esophageal dilation and is attempting first postprocedure oral intake
c.
Client who had an esophagectomy with a respiratory rate of 32/min
d.
Client who underwent hernia repair, reporting incisional pain of 7/10
ANS: C
The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for.
DIF: Analyzing/Analysis REF: 1121
The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy:
Physical Assessment
Skin dry
Urine output 20 mL/hr
NG tube patent with 100 mL brown drainage/hr
Restless
Vital Signs
Pulse: 128 beats/min
Blood pressure: 88/50 mm Hg
Respiratory rate: 20 on ventilator
Cardiac output: 2.1 L/min
Oxygen saturation: 99%
Physician Orders
Normal saline at 75 mL/hr
Morphine sulfate 2 mg IV push every 1 hr PRN pain
Intake and output every hour
Vital signs every hour
Vancomycin (Vancocin) 1 g IV every 8 hr
What action by the nurse is best?
a.
Administer the prescribed pain medication.
b.
Consult the surgeon about a different antibiotic.
c.
Consult the surgeon about increased IV fluids.
d.
Have respiratory therapy reduce the respiratory rate.
ANS: C
This client’s vital signs, cardiac output, dry skin, and urine output indicate hypovolemia or possible hypotension resulting from pressure placed on the posterior heart during surgery. The client needs more fluids, so the nurse should consult with the surgeon about increasing the fluid intake. The client may be restless as a result of the hypotension and may not need pain medication at this time. There is no reason to request a different antibiotic. The respiratory rate does not need to be adjusted.
DIF: Analyzing/Analysis REF: 1121
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.)
a.
Delayed gastric emptying
b.
Eating large meals
c.
Hiatal hernia
d.
Obesity
e.
Viral infections
ANS: A, B, C, D
Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is.
DIF: Remembering/Knowledge REF: 1111
