A&E II Exam 2 questions and answers
1.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.: ANS: D
The drainage in the NG tube should initially be brown with old blood. The
presence of bright red blood indicates bleeding. The nurse should take a
set of vital signs to assess for shock and then notify the surgeon.
Documentation should occur but is not the first thing the nurse should
do. The nurse should not wait an additional hour to reassess.
2.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.": ANS: A
Nutritional and lifestyle changes need to continue after surgery as the
procedure does not offer a lifetime cure. The other statements show
good understanding.
3.A client with an esophageal tumor has difficulty swallowing and has been
working with a speech-language pathologist. What assessment finding by
the nurse indicates that the priority goal for this problem is being met?
a. Choosing foods that are easy to swallow
b. Lungs clear after meals and snacks
c. Properly performing swallowing exercises
d. Weight unchanged after 2 weeks: ANS: B
All these assessment findings are positive for this client. However, this
client is at high risk for aspiration. Clear lungs after eating indicates no
aspiration has occurred. Choosing easy-to-swallow foods, performing
swallowing checks, and having an unchanged weight do not assess
aspiration, and therefore do not indicate that the priority goal has been
met.
4.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
, A&E II Exam 2 questions and answers
c. Nissen fundoplication
d. Photodynamic therapy: ANS: B
, A&E II Exam 2 questions and answers
Esophageal dilation can provide immediate relief of esophageal strictures
that impair swallowing. Enteral tube feeding is a method of providing
nutrition when dysphagia is severe, but esophageal dilation would be
attempted before this measure is taken. Nissen fundoplication is
performed for severe gastroesophageal reflux disease.
Photodynamic therapy is performed for esophageal cancer.
5.A client is scheduled for a traditional esophagogastrostomy. All preop-
erative 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.: ANS: B
Clients facing this long, difficult procedure are often anxious and fearful.
The nurse should now assess the client's psychosocial status and
provide the care and teaching required based on this assessment. An
intensive care unit tour may help decrease stress but is too limited in
scope to be the best response. Documentation should be thorough, but
the nurse needs to do more than document. The client should begin
nutritional supplements prior to the operation, but again this response is
too limited in scope.
6.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 client's 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.: ANS: A
The priorities of care are airway, breathing, and circulation. The priority
option is to assess oxygenation. This occurs before diagnostic or
therapeutic procedures. The client needs two large-bore IVs as a
trauma client, but oxygenation comes first.
7.A client has a nasogastric (NG) tube. What action by the nursing
student requires the registered nurse to intervene?
a.
Checking tube placement every 4 to 8 hours b.
Monitoring and documenting drainage from the NG tube c.
Pinning the tube to the gown so the client cannot turn the head d.
1.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.: ANS: D
The drainage in the NG tube should initially be brown with old blood. The
presence of bright red blood indicates bleeding. The nurse should take a
set of vital signs to assess for shock and then notify the surgeon.
Documentation should occur but is not the first thing the nurse should
do. The nurse should not wait an additional hour to reassess.
2.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.": ANS: A
Nutritional and lifestyle changes need to continue after surgery as the
procedure does not offer a lifetime cure. The other statements show
good understanding.
3.A client with an esophageal tumor has difficulty swallowing and has been
working with a speech-language pathologist. What assessment finding by
the nurse indicates that the priority goal for this problem is being met?
a. Choosing foods that are easy to swallow
b. Lungs clear after meals and snacks
c. Properly performing swallowing exercises
d. Weight unchanged after 2 weeks: ANS: B
All these assessment findings are positive for this client. However, this
client is at high risk for aspiration. Clear lungs after eating indicates no
aspiration has occurred. Choosing easy-to-swallow foods, performing
swallowing checks, and having an unchanged weight do not assess
aspiration, and therefore do not indicate that the priority goal has been
met.
4.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
, A&E II Exam 2 questions and answers
c. Nissen fundoplication
d. Photodynamic therapy: ANS: B
, A&E II Exam 2 questions and answers
Esophageal dilation can provide immediate relief of esophageal strictures
that impair swallowing. Enteral tube feeding is a method of providing
nutrition when dysphagia is severe, but esophageal dilation would be
attempted before this measure is taken. Nissen fundoplication is
performed for severe gastroesophageal reflux disease.
Photodynamic therapy is performed for esophageal cancer.
5.A client is scheduled for a traditional esophagogastrostomy. All preop-
erative 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.: ANS: B
Clients facing this long, difficult procedure are often anxious and fearful.
The nurse should now assess the client's psychosocial status and
provide the care and teaching required based on this assessment. An
intensive care unit tour may help decrease stress but is too limited in
scope to be the best response. Documentation should be thorough, but
the nurse needs to do more than document. The client should begin
nutritional supplements prior to the operation, but again this response is
too limited in scope.
6.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 client's 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.: ANS: A
The priorities of care are airway, breathing, and circulation. The priority
option is to assess oxygenation. This occurs before diagnostic or
therapeutic procedures. The client needs two large-bore IVs as a
trauma client, but oxygenation comes first.
7.A client has a nasogastric (NG) tube. What action by the nursing
student requires the registered nurse to intervene?
a.
Checking tube placement every 4 to 8 hours b.
Monitoring and documenting drainage from the NG tube c.
Pinning the tube to the gown so the client cannot turn the head d.
