Nokea
The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which assessment. (Select all that apply.)
- A. Aphasia
- B. Dysphagia
- C. Eructation
- D. Halitosis
- E. Weight gain
Correct Answer: B,C,D
Rationale: Esophageal disorders commonly cause dysphagia (difficulty swallowing), eructation (belching), halitosis (bad breath), and weight loss. Aphasia is unrelated, as it involves speech difficulties typically from neurological issues.
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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 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.
Correct Answer: D
Rationale: Bright red blood in the NG tube indicates possible bleeding, which requires immediate assessment. Taking vital signs first helps evaluate for shock, which is a priority before notifying the surgeon. Documentation and reassessment are secondary actions.
The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assisting with position changes and getting out of bed
- B. Keeping the head of the bed elevated to at least 30
- C. Turning the client
- D. Reminding the client to use the spirometer every 4 hours
- E. Taking and recording vital signs per hospital protocol
- F. Titrating oxygen based on the client oxygen saturations
Correct Answer: A,B,D
Rationale: UAPs can assist with mobility, maintain bed elevation, and remind about spirometer use (though it should be every 1-2 hours). Oxygen titration requires nursing judgment and cannot be delegated.
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.
Correct Answer: A
Rationale: Nutritional and lifestyle changes must continue after fundoplication, as it does not offer a lifetime cure. The other statements reflect accurate understanding of postoperative expectations.
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.