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 D
Explanation
A. Gabapentin is an anticonvulsant commonly used to treat neuropathic pain, including trigeminal neuralgia. It works by stabilizing nerve activity and is appropriate for this condition.
B. Carbamazepine is considered the first-line treatment for trigeminal neuralgia as it decreases nerve impulses, which helps reduce pain. It is a commonly prescribed medication for this condition.
C. Baclofen is a muscle relaxant and can be used in combination with anticonvulsants to treat trigeminal neuralgia by reducing muscle spasms associated with nerve irritation.
D. Oxycodone is an opioid analgesic that treats general pain but is not typically effective for the specific type of neuropathic pain experienced in trigeminal neuralgia. Opioids do not address the underlying nerve activity and are not recommended for long-term management of this condition.
Correct Answer is C
Explanation
A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.