The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?
Anxiety and grieving related to progression of disease.
Chronic pain related to tissue destruction by tumor.
Risk for aspiration related to difficulty swallowing.
Imbalanced nutrition less than body requirements.
The Correct Answer is C
Choice A rationale
Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.
Choice B rationale
Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.
Choice C rationale
Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.
Choice D rationale
Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.
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Correct Answer is D
Explanation
Choice A rationale
Storing the medication at room temperature is appropriate for ipratropium inhalers. This ensures the medication remains effective and safe for use.
Choice B rationale
Attaching a spacer device to the inhaler is recommended for patients using ipratropium inhalers. A spacer helps deliver the medication more effectively to the lungs and reduces the risk of side effects.
Choice C rationale
Rinsing the mouth after each use of the inhaler is a good practice to prevent oral thrush and other side effects. It is a recommended step in the proper use of inhalers.
Choice D rationale
Priming the inhaler with 7 pumps is excessive. Typically, inhalers need to be primed with 2-4 pumps before first use or if they haven’t been used for a while. Over-priming can waste medication and indicate a need for additional teaching.
Correct Answer is A
Explanation
Choice A rationale
Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.
Choice B rationale
Identifying effective pain relief measures is important but does not directly assess the quality of pain.
Choice C rationale
Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.
Choice D rationale
Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.