Nokea
A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is best?
- A. Delegate oral care every 4 hours
- B. Monitor and record the client's intake
- C. Place the client in a semi- or high-Fowler's position
- D. Clean the tracheostomy site daily
Correct Answer: C
Rationale: To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The tracheostomy site may or may not need to be cleaned daily, and this is not the priority action.
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A nurse assesses a clients oral cavity and observes the condition depicted in the photo below. What action by the nurse is best?
- A. Document the findings and continue monitoring
- B. Refer the client to a dentist immediately
- C. Apply a topical anesthetic to the lesion
- D. Educate the client on oral hygiene practices
Correct Answer: B
Rationale: Given the context of oral cavity assessment and the presence of a condition depicted in a photo, the best action is to refer the client to a dentist immediately for further evaluation, as the condition could indicate a serious issue such as oral cancer. Documenting and monitoring is important but not sufficient as the primary action. Applying a topical anesthetic is inappropriate without a diagnosis, and education on oral hygiene is secondary to professional evaluation.
A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first?
- A. Client having a radial neck dissection tomorrow who is asking questions
- B. Client who had a tracheostomy 4 hours ago and needs frequent suctioning
- C. Client who is a day postoperative for an oral tumor resection who is reporting pain
- D. Client waiting for discharge instructions after a small tumor resection
Correct Answer: B
Rationale: The client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last.
A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety?
- A. Agree on a postoperative communication method
- B. Explain the staff will answer the call sign promptly
- C. Give the client a Magic Slate to write on postoperatively
- D. Reassure the client that you will take care of all of his or her needs
Correct Answer: A
Rationale: Before surgery that interrupts the client's ability to communicate, the nurse, client, and family (if possible) agree on a method of communication in the postoperative period. The client may prefer a slate and may not be able to communicate in writing. Reassuring the client and telling him or her that you will take care of all of his or her needs does not help the client be an active participant in care. Ensuring that the staff will answer the call sign promptly is not a guarantee and will occur.
The nurse reads a clients chart and sees that the health care provider assessed mucosal erythropplasia. What does the client needs to what that this means for the client?
- A. Early sign of oral cancer
- B. Fungal mouth infection
- C. Inflammation of the gums
- D. Obvious oral tumor
Correct Answer: A
Rationale: Mucosal erythropplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.
A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the student nurse regarding the specialized nurse to interview?
- A. Assisting the client to perform oral care every 2 hours
- B. Preparing to administer a viscous lidocaine gargle
- C. Translating the client nurse to administer a (Mycomatin)
- D. Teaching the client to use a soft-bristled toothbrush
Correct Answer: B
Rationale: Viscous lidocaine gargles or mouthwashes are sometimes prescribed for clients with stomatitis and pain. However, the numbing effect can lead to choking or mouth burns from food. This client already has difficulty swallowing, so this medication is not appropriate. Therefore, the nurse should intervene when the student prepares to administer this preparation. The other options are correct actions.