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 C
Explanation
A. While no episodes of diarrhea may be beneficial, it is not a direct indicator of the effectiveness of ondansetron, which is used primarily to prevent nausea and vomiting.
B. Maintaining a normal hemoglobin level is not an expected outcome related to ondansetron, as it does not influence blood counts.
C. The ability to tolerate oral fluid intake indicates that the client is managing nausea effectively, demonstrating that ondansetron is working as intended.
D. Hair loss is a common side effect of many chemotherapeutic agents, and ondansetron does not affect this outcome. Therefore, it is not an appropriate indicator of the medication's effectiveness.
Correct Answer is A
Explanation
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.