Nokea
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.
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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 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.
A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations?
- A. Coal miner
- B. Electrician
- C. Metal worker
- D. Textile worker
- E. Plumber
Correct Answer: A,C,D,E
Rationale: The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAH), which are known carcinogens. Electricians do not have this risk.
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.
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.