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?

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.

A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.