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The nurse determines that a client who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the nurse's priority when suctioning this client?

Avoid applying suction on or near the suture line.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care?

The client will be monitored closely to detect malignant changes.

A medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client?

Indicates acceptance of altered appearance and demonstrates positive self-image

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom?

Regurgitation of undigested food

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries?

Inadequate nutrition and decreased saliva production can cause cavities

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client most likely faces the highest immediate risk of oral cancer?

A 65-year-old man with alcoholism who smokes

A nurse is caring for a client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action?

Promptly report these indications of venous congestion.

A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Assess for a patent airway.

A client who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What should the goals of physical therapy for this client include?

Promoting maximum shoulder function

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer?

Early diagnosis and treatment of gastroesophageal reflux disease

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body?

Glucagon

A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend what action?

Use warm saline to rinse the mouth as needed.

A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies?

Metastases are common and respond poorly to treatment.

A client has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this client?

Placing the client in Fowler position

A client 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 client's discharge education?

Promotion of adequate nutrition

The client is experiencing painful oral lesions following radiation for oropharyngeal cancer. Which instruction should the nurse give this client?

Eat soft or liquid foods.

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action?

Report this finding promptly to the health care provider and remain with the client.

A nurse is providing care for a client whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis?

Ineffective tissue perfusion

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?

The client's swallowing ability

A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care?

Positioning the client to prevent gastric reflux

A nurse is caring for a client who has had surgery for oral cancer. When addressing the client's long-term needs, the nurse should prioritize interventions and referrals with what goal?

Enhancement of verbal communication

A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the health care provider immediately for what finding?

60 mL of milky or cloudy drainage

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug?

Metoclopramide

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

"Instead of eating three meals a day, try eating smaller amounts more often."

A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this client, what would the nurse be sure to include?

Avoiding chewing food for the specified number of weeks after surgery

A nurse is caring for a client who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the client's appetite?

Encourage the family to bring in the client's favorite foods.

A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) of this stage of the disease? Select all that apply.

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

Perforation into the mediastinum, Erosion into the great vessels, Obstruction of the esophagus

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent?

Aspiration

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly?

"I flush my tube with water before and after each of my medications."

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

The nurse is administering medications to a client through a feeding tube. Which action should the nurse take?

Administer each medication separately.

A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response?

“Regurgitation and aspiration are less likely.”

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care?

Measure and record drainage.

The nurse is caring for a client who had a low-profile gastrostomy device placed. Which instruction should the nurse give the client and family?

Bring the connection tubing if going to the hospital.

A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client?

Insertion is likely to cause some gagging.

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include?

Use client assessment findings to determine tolerance of feedings.

A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take?

Wear personal protective equipment.