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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

Answer and Explanation

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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A. Encourage and assist with use of incentive spirometer every hour while awake B. Assist client out of bed on post-operative day 1 C. Reposition client every four hours while in bed D. Utilize aseptic technique while changing dressing E. Maintain TEDS and SCD's while in bed

Correct Answer is ["A","D","E"]

Explanation

A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.

B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.

C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.

D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.

E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.

A. Soft, low sofa. B. Dining room chair with armrests. C. Canvas lawn chair. D. Desk type, swivel chair.

Correct Answer is B

Explanation

A. A soft, low sofa can make it difficult for the client to rise and sit safely after surgery, which may risk hip dislocation.

B. A dining room chair with armrests provides support for the client to help them sit down and stand up safely, making this the most appropriate choice.

C. A canvas lawn chair typically does not provide adequate support or height, which can complicate the sitting and standing process post-surgery.

D. A desk type, swivel chair may not be stable or supportive enough for the client, increasing the risk of falls or injury after the hip replacement.

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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?

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Correct Answer is ["A","D","E"]

Explanation

Correct Answer is B

Explanation

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Take full exam for free 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?

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Explanation

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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?