A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.
Which of the following findings should the nurse identify as the priority?

Dysphagia.

Xerostomia.

Excoriation of the skin on the neck and chest.

Client reports a pain level of 6 on a scale from 0 to 10.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.

Choice B rationale:

Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.

Choice C rationale:

Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.

Choice D rationale:

The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.

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Correct Answer is C

Explanation

The correct answer is choice c. Limit fluid intake with meals.

Choice A rationale:

Administering a bronchodilator after meals is not ideal because bronchodilators are typically given before meals to help open the airways and make breathing easier during eating.

Choice B rationale:

Ambulating the client before each meal might cause fatigue, making it harder for the client to eat and potentially decreasing their overall intake.

Choice C rationale:

Limiting fluid intake with meals can help prevent the client from feeling too full, which can make it easier for them to consume more solid food. This is particularly important for clients with COPD who may already have a reduced appetite and difficulty eating large amounts at once.

Choice D rationale:

Offering three large meals each day is not recommended for clients with COPD. Smaller, more frequent meals are generally better tolerated and can help prevent the feeling of fullness that can make breathing more difficult.

A. Tape the tube to the child's cheek. B. Apply water-soluble lubricant to the site. C. Attach an extension tube to the site's opening prior to use. D. Secure the tubing to the child's abdomen. E. None F. None

Correct Answer is D

Explanation

A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

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A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.
Which of the following findings should the nurse identify as the priority?