A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Be alert for non-verbal clues for pain or discomfort

Answer for the client during rounds with the physician

Assessment of the ability to cough and swallow

Provide enough time for the client to respond

Answer and Explanation

The Correct Answer is C

A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.

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Correct Answer is A

Explanation

A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.

A. Using a commercial medicine to remove a corn B. Soaking feet daily in cool water C. Utilizing a mirror to examine the soles of the feet D. Cutting nails in a concave manner

Correct Answer is C

Explanation

A. Using a commercial medicine to remove a corn is not recommended, as it can cause skin damage and infection; diabetic clients should seek professional care for such issues.
B. Soaking feet daily in cool water can lead to skin maceration and should generally be avoided; it is better to wash and dry feet gently.
C. Utilizing a mirror to examine the soles of the feet indicates proper awareness and self-care, as diabetic clients need to monitor for any injuries or changes that could lead to complications.
D. Cutting nails in a concave manner is incorrect; nails should be cut straight across to prevent ingrown toenails.

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A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse teaches a diabetic client how to perform foot care. Which action by the client would indicate that they can correctly perform foot care?

Correct Answer is C

Explanation

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