Nokea
A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease?
- A. Perforation into the mediastinum
- B. Development of an esophageal lesion
- C. Erosion into the great vessels
- D. Painful swallowing
- E. Obstruction of the esophagus
Correct Answer: A,C,E
Rationale: In the later stages of esophageal cancer, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Painful swallowing and the emergence of a lesion are early signs of esophageal cancer.
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The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient?
- A. Avoid applying suction on or near the suture line.
- B. Position patient on the non operative side with the head of the bed down.
- C. Assess the patients ability to perform self-suctioning.
- D. Evaluate the patients ability to swallow saliva and clear fluids.
Correct Answer: A
Rationale: The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Self-suctioning may be unsafe because the patient may damage the suture line. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patients ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patients need for suctioning.
A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status?
- A. Ensure that none of the patients visitors has an infection.
- B. Arrange for a diet that is high in protein and low in fat.
- C. Administer colony stimulating factors (CSFs) as ordered.
- D. Prepare to administer chemotherapeutics as ordered.
Correct Answer: A
Rationale: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.
A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis?
- A. Risk for Disuse Syndrome
- B. Unilateral Neglect
- C. Risk for Trauma
- D. Ineffective Tissue Perfusion
Correct Answer: D
Rationale: Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.
A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?
- A. Keep the head of the bed lowered.
- B. Drink a cup of hot tea before bedtime.
- C. Avoid carbonated drinks.
- D. Eat a low-protein diet.
Correct Answer: C
Rationale: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.
A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education?
- A. Resumption of activities of daily living
- B. Pain control
- C. Promotion of adequate nutrition
- D. Strategies for promoting communication
Correct Answer: C
Rationale: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the patients nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery.