The nurse is caring for a client receiving radiation therapy for treatment of oral cancer. Which new finding is the greatest concern?
Stomatitis
Stridor
Nausea
Xerostomia
The Correct Answer is B
A. Stomatitis is a common side effect of radiation therapy for oral cancer, and while it requires management, it is not immediately life-threatening.
B. Stridor indicates potential airway obstruction, which is a critical and urgent condition that requires immediate intervention, making it the greatest concern among the options presented.
C. Nausea is a typical side effect of cancer treatment but is usually manageable and not considered an immediate threat.
D. Xerostomia, or dry mouth, is another common side effect of radiation to the head and neck, but it is not as urgent as the risk of airway compromise indicated by stridor.
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Correct Answer is B
Explanation
A. Washing the skin with water is generally acceptable, but applying scented lotion is not recommended as it may irritate the skin or interfere with treatment; only specific products as advised by the healthcare provider should be used.
B. Skin treatment markings are important for ensuring correct targeting of radiation during therapy and should remain intact for the duration of treatment to avoid misalignment.
C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.
Correct Answer is C
Explanation
A. The absence of bowel sounds shortly after surgery is a common finding and does not necessarily indicate a complication at this time; it is expected during the initial postoperative period.
B. An SPO2 of 90% while the client is asleep is concerning, but it does not take precedence over signs of possible surgical complications that could require immediate intervention.
C. Increasing abdominal distention is a critical sign that could indicate serious complications such as an anastomotic leak, bowel obstruction, or intra-abdominal bleeding, and it requires immediate notification of the surgeon for further evaluation and potential intervention.
D. A small amount of green-tinged fluid from the nasogastric tube is typical postoperatively and does not necessitate immediate notification to the surgeon unless the volume is excessive or other concerning signs are present.