A patient who has undergone an esophagectomy for esophageal cancer develops increasing pain, fever, and dyspnea when a full liquid diet is started postoperatively. The nurse recognizes that these symptoms are most indicative of:
An intolerance to the feedings
Esophageal perforation with fistula formation into the lung
Extension of the tumor into the aorta
Leakage of fluids into the mediastinum
The Correct Answer is B
A. An intolerance to the feedings might cause discomfort, but it would not typically cause increasing pain, fever, and dyspnea. These symptoms are more indicative of a serious complication.
B. Esophageal perforation with fistula formation into the lung is the most likely cause of these symptoms. A perforation can lead to leakage of gastric contents into the pleural space or mediastinum, causing fever, pain, and respiratory distress. The formation of a fistula between the esophagus and the lung would lead to dyspnea.
C. Extension of the tumor into the aorta is a rare complication that would typically manifest with symptoms related to cardiovascular issues, not gastrointestinal symptoms like fever and dyspnea.
D. Leakage of fluids into the mediastinum is a possible cause of the symptoms, but esophageal perforation with a fistula into the lung is more directly linked to these specific symptoms, especially dyspnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fecal output from a new colostomy typically begins within 2 to 4 days, not within 24 hours. This is due to the time needed for bowel function to resume after surgery.
B. A small amount of bleeding around the stoma can occur as part of normal healing, especially in the first few days after surgery. It should not be excessive or prolonged.
C. Raw vegetables and high-fiber foods should be avoided immediately after surgery as they can irritate the digestive tract and cause blockages in the stoma. A low-fiber diet is recommended initially.
D. The stoma should initially be red or pink in color, not purplish. A purplish color could indicate impaired circulation, which would require medical attention.
Correct Answer is ["A","C"]
Explanation
A. Planning for periods of rest during activities and monitoring the client's oxygen saturation are essential interventions for a client with pneumonia. Rest helps conserve energy and reduces the workload on the respiratory system, while monitoring oxygen saturation ensures that the client is maintaining adequate oxygen levels, which is crucial in pneumonia.
B. Placing the client on strict fluid restriction is not appropriate for pneumonia. In fact, adequate hydration is important to help thin respiratory secretions and facilitate expectoration.
C. Placing the client on oxygen is often necessary for clients with pneumonia, especially if they are hypoxic or have difficulty maintaining adequate oxygen levels. Supplemental oxygen supports the respiratory system and improves oxygenation.
D. Restricting the client's smoking to 5 cigarettes per day is not an appropriate intervention. Smoking should be completely stopped to help reduce the risk of further respiratory complications. Smoking cessation is a priority in managing respiratory conditions like pneumonia
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