Nokea
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.
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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.
The nurse is caring for a client with sialadenitis. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Applying warm compresses
- B. Massaging salivary glands
- C. Offering fluids every hour
- D. Providing lemon glycerin swabs
- E. Reminding the client to avoid speaking
Correct Answer: A,C
Rationale: The UAP can apply warm compresses and offer fluids. Massaging salivary glands can be done, but not by the UAP. Lemon glycerin swabs are drying and should not be used. Speaking has no effect on this condition.
A female client hospitalized for an unrelated problem has a large partly-white lesion on her lip, to which she is the nurse or health care provider. What action by the nurse is best?
- A. Ask the client why her appearance is so important
- B. Ignore the lesion since the client and not discuss it
- C. Inform the client that early-stage cancer is curable
- D. Know with the client to establish a trusting relationship
Correct Answer: D
Rationale: Clients with oral cancers often have body image difficulties due to the location of the tumor or the results of surgical treatment. This client appears to be using denial to cope with this problem. The nurse should work to establish a helping-trusting relationship in hopes that the client will be amenable to future discussions about the lesion. Asking why questions often puts people on the defensive and should be avoided. Ignoring the lesion is not being an advocate for the client. Education is important, but right now the client is in denial, so this information will not seem relevant to her.
A client is prescribed cotusimma (Ebitus) for oral cancer and asks the nurse how it works. What response by the nurse is best?
- A. Blocks the epidermal growth factor
- B. Cuts off the tumor's blood supply
- C. Prevents tumor extension
- D. Targets rapidly dividing cells
Correct Answer: A
Rationale: Cetusimma (Ebitus) targets and blocks the epidermal growth factor, which contributes to the growth of oral cancers. The other explanations are not correct.
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.