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 C

Explanation

A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.

A. Encourage client to rinse the mouth twice a day with mouthwash B. Encourage client to perform mouth care before and after every meal C. Offer the client 3 meals per day with a snack at bedtime D. Assess the client's oral pain level once a shift

Correct Answer is B

Explanation

A. Rinsing the mouth with mouthwash is not sufficient for managing oral lesions, and some mouthwashes may contain alcohol that can further irritate the lesions; therefore, this intervention is inadequate.
B. Performing mouth care before and after every meal can help minimize discomfort, remove debris, and maintain oral hygiene, which is crucial for someone with painful oral lesions to encourage better nutritional intake.
C. Offering three meals with a bedtime snack may not be effective if the client is unable to eat comfortably; focusing on smaller, more frequent meals or nutrient-dense options may be more beneficial.
D. While assessing oral pain is important, it should occur more frequently than once per shift to ensure ongoing management and adjustment of care based on the client’s comfort and needs.

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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

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Explanation

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