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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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.
Choice B rationale
Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.
Choice C rationale
Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.
Choice D rationale
Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.
Correct Answer is D
Explanation
Choice A rationale
Laying down on each side with knees bent and breathing from the abdomen is not an effective technique for improving gas exchange in emphysema patients.
Choice B rationale
Increasing the breathing rate for a full 30 seconds can lead to hyperventilation and is not recommended for improving gas exchange.
Choice C rationale
Raising hands above the head to expand the diaphragm is not a recognized technique for improving gas exchange in emphysema patients.
Choice D rationale
Drawing air in through the nose and exhaling slowly through pursed lips is an effective technique for improving gas exchange in emphysema patients. This method helps to keep the airways open longer and improves the removal of trapped air.