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
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 B
Explanation
A. Stomatitis is a common side effect of radiation therapy for oral cancer, and while it requires management, it is not immediately life-threatening.
B. Stridor indicates potential airway obstruction, which is a critical and urgent condition that requires immediate intervention, making it the greatest concern among the options presented.
C. Nausea is a typical side effect of cancer treatment but is usually manageable and not considered an immediate threat.
D. Xerostomia, or dry mouth, is another common side effect of radiation to the head and neck, but it is not as urgent as the risk of airway compromise indicated by stridor.
Correct Answer is B
Explanation
A. 1500: This is incorrect
B. The calculation is as follows:
Remaining fluid: 600 mL
IV rate: 100 mL/hour
Time to empty the bag: 600 mL ÷ 100 mL/hour = 6 hours
Adding 6 hours to the report time:
0700 + 0600 = 1300
The correct answer is 1300.
C. 1400: This is incorrect
D. 1500: This is incorrect