Nokea
A client who has recovered from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort?
- A. Keeping the head of the bed elevated.
- B. Positioning the client flat on the abdomen or side.
- C. Providing a tracheostomy tray near the bed.
- D. Turning the client's head to the side.
Correct Answer: A
Rationale: It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth until the client has recovered from anesthesia. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
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The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response?
- A. I can arrange a nutritional consultation.
- B. Cold liquids may help soothe the sensitivity.
- C. An anesthetic mouthwash may be used, but I will need to consult with the primary provider.
- D. A special diet may be necessary based on your ability to chew and swallow.
- E. Your doctor may prescribe a systemic analgesic for pain relief if necessary.
Correct Answer: A,C,D,E
Rationale: When responding to a client reporting severe mouth sensitivity due to oral cancer, the nurse should inform the client of possible options for managing the sensitivity. These include nutritional consultations, the use of anesthetic mouthwash if approved by the primary provider, the formulation of a special diet around the client's ability to chew and swallow, and a systemic analgesic for pain relief if the provider deems it necessary. It is inaccurate for the nurse to respond that cold liquids may soothe the sensitivity, because cold and hot liquids may increase the discomfort of sensitive oral tissues.
The nurse is managing the care of a client needing gastrointestinal suction and decompression with a Levin tube. Place the steps of initiating suction and decompression in the order the nurse should perform them.
- A. Insert the gastric decompression tube.
- B. Locate the suction source.
- C. Connect the decompression tube to the suction.
- D. Select suction according to health care provider prescription.
Correct Answer: B,D,A,C
Rationale: The nurse should locate the suction source, usually a wall outlet or portable machine. The nurse should then adjust the suction level on the wall outlet or portable machine to provide the amount and frequency of suction specified by the primary provider. The nurse should select intermittent high, low, or continuous suction when using a Salem sump tube; the nurse should select low intermittent suction when using a Levin tube because the single lumen may adhere to the lining of the stomach during continuous suction (if the tube is used only to obtain specimens for diagnostic purposes, manual suction may be achieved by attaching a syringe to the end of the tube and drawing back on the plunger). Finally, the nurse should insert the gastric decompression tube in accordance with accepted standards and connect it to the suction.
The nurse is preparing to administer famotidine to a client with gastroesophageal reflux disease. Which safety warning should the nurse consider when administering the medication?
- A. Do not allow client to take maximum dose for more than 2 weeks without medical consultation.
- B. Review client's cardiac status and sodium restrictions.
- C. Do not give other oral drugs within 1 to 2 hours of administering the medication.
- D. Be aware that long-term use may be associated with bone fractures
Correct Answer: A
Rationale: The safety warning that the nurse should consider is that the client should not take the maximum dose of famotidine for more than 2 weeks without medical consultation, because it is a histamine H2 antagonist. Reviewing cardiac status and sodium restrictions is a consideration for sodium bicarbonate. Not giving oral drugs within 1 to 2 hours is a consideration for antacids. Long-term use being associated with bone fractures is a consideration for proton pump inhibitors.
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?
- A. I will eat two large meals a day, instead of three.
- B. I will eliminate bothersome foods from my diet.
- C. I will plan to sleep flat without pillows.
- D. I will start taking a nap after meals, when possible.
Correct Answer: B
Rationale: Irritating foods such as spices, caffeine, and alcohol should be avoided because doing so will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.
The nurse has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply.
- A. Observe for respiratory distress.
- B. Measure pH of feeding tube aspirates.
- C. Auscultate.
- D. Monitor aspirate for sudden change in amount.
- E. Mark the tube at the exit site.
- F. Obtain radiographic confirmation.
Correct Answer: A,B,D,E,F
Rationale: The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.