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 D
Explanation
A. Constipation is not a direct consequence of external beam radiation to the lung; it may occur due to other factors, such as reduced mobility or medications, but it is not specifically anticipated from this treatment.
B. Alopecia is typically associated with radiation therapy to areas where hair grows, such as the head, rather than the lung area, so it is not expected in this case.
C. Increased saliva is not a common side effect of radiation to the lungs; rather, some patients may experience dry mouth due to treatment to nearby structures.
D. Esophagitis is a well-known complication of radiation therapy to the chest area, as the esophagus can be affected by radiation exposure, leading to inflammation and discomfort in swallowing.