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 A
Explanation
A. A garden salad may contain raw vegetables, which can harbor bacteria and pose a risk of infection for a client with neutropenia, making this the concerning choice.
B. Applesauce is typically safe as it is a processed food that has been cooked, reducing the risk of bacterial contamination.
C. A baked potato is also safe as long as it is properly cooked and handled, which minimizes the risk of foodborne illness.
D. Steamed broccoli is safe because the cooking process eliminates harmful bacteria, making it a better choice for someone with neutropenia.
Correct Answer is C
Explanation
A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.