Nokea
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 clients 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.
Correct Answer: A
Rationale: Subcutaneous emphysema suggests possible airway or esophageal injury. The priority is ensuring airway and breathing (assessing oxygenation) before diagnostic or therapeutic interventions, following the ABC (airway, breathing, circulation) priority framework.
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A client has been discharged to an inpatient rehabilitation center after an esophagogastrectomy. What menu selections by the client at the rehabilitation center indicate a good understanding of dietary instructions? (Select all that apply.)
- A. Boost supplement
- B. Greek yogurt
- C. Scrambled eggs
- D. Whole milk shake
- E. Whole wheat toast
Correct Answer: A,B,C,D
Rationale: High-protein, high-calorie, easy-to-swallow foods like Boost, Greek yogurt, scrambled eggs, and whole milk shakes are appropriate post-esophagogastrectomy. Whole wheat toast is dry and harder to swallow, making it a poor choice.
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.
Correct Answer: B
Rationale: Clients facing esophagogastrostomy are often anxious due to the procedure's complexity. Assessing psychosocial status is critical to address anxiety and provide tailored support, making it the best action compared to the more limited scope of the other options.
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.
Correct Answer: B
Rationale: Gaviscon should be taken with food in the stomach to form a protective barrier. It can be taken with meals at any time, and its mechanism of action is not to decrease stomach acid but to create a foam barrier to prevent reflux.
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
Correct Answer: B
Rationale: Esophageal dilation provides immediate relief for strictures impairing swallowing. Enteral feeding may be used later if dilation fails, while Nissen fundoplication addresses reflux, and photodynamic therapy is for cancer treatment, not immediate swallowing relief.
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 reinsert the NG tube.
- D. Take a set of vital signs.
Correct Answer: B
Rationale: Standard precautions require putting on gloves first to protect the nurse from exposure to blood and body fluids. This is the priority before assessing vital signs, notifying the surgeon, or attempting to reinsert the NG tube.