ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 45 : Caring for Clients With Disorders of the Upper Gastrointestinal Tract Questions
Question 1 of 5
The nurse is caring for a client with hypovolemia related to prolonged vomiting and decreased intake of oral fluids. What activity(ies) should the nurse include in the client's plan of care? Select all that apply.
Correct Answer: D,E
Rationale: The nurse should monitor the client's weight daily and assess skin turgor and mucous membranes. The nurse should offer clear liquids in small amounts. Slow introduction of fluids enables the client to develop tolerance and determine if it is possible to advance the diet. The nurse should recommend the use of commercial, over-the-counter beverages that contain electrolytes. If the client's urine output drops below 17 oz (500 mL) per day, the nurse should notify the primary provider because this indicates severe dehydration and the need for IV replacement fluids.
Question 2 of 5
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
Correct Answer: A,B
Rationale: The nurse should inform the client that oral cancer is characteristically asymptomatic in its early stage, though lesions, lumps, or other abnormalities may be present on the lips and mouth. While it is true that oral cancer may cause difficulty eating or tasting food, pain and numbness, and persistent hoarseness, these events occur later in the disease's progression and are not relevant in discussion of the early stage.
Question 3 of 5
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?
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.
Question 4 of 5
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.
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.
Question 5 of 5
The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.
Correct Answer: A
Rationale:
Step 1: 2 * 8 oz = 16 oz
Step 2: 1 oz : 30 mL :: 16 oz : X mL X = 480 mL
Step 3: 480 mL / 80 mL = 6 hours