A client has esophageal cancer.Which intervention by the nurse takes priority?
Allowing grieving
Preventing aspiration
Managing pain relief
Maintaining nutritional intake
The Correct Answer is B
Choice A rationale
While allowing grieving is an important aspect of holistic care for a client with esophageal cancer, it is not the priority nursing intervention. Emotional support and counseling are crucial, but they do not take precedence over interventions aimed at maintaining the client’s physical health.
Choice B rationale
Preventing aspiration is the priority nursing intervention for a client with esophageal cancer. Aspiration, or the inhalation of food, stomach acid, or saliva into the lungs, can lead to pneumonia and other serious complications. Therefore, measures to prevent aspiration, such as educating the client on safe swallowing techniques, elevating the head of the bed during meals, and monitoring for signs of aspiration, are crucial.
Choice C rationale
Managing pain relief is an important aspect of care for a client with esophageal cancer, but it is not the priority nursing intervention. Pain management strategies, such as administering prescribed analgesics and providing comfort measures, are part of a comprehensive care plan
but do not take precedence over interventions aimed at preventing immediate life-threatening complications like aspiration.
Choice D rationale
Maintaining nutritional intake is an important aspect of care for a client with esophageal cancer, but it is not the priority nursing intervention. Nutritional support, such as providing a balanced diet, encouraging small frequent meals, and possibly arranging for a consultation with a dietitian, are important but do not take precedence over interventions aimed at preventing immediate life-threatening complications like aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assuming a position with legs and rectum lower than the stomach is not typically recommended for managing postoperative abdominal discomfort.
Choice B rationale
Using a straw can actually increase the amount of air swallowed, which can contribute to gas and bloating.
Choice C rationale
Ambulation, or walking, is often recommended after abdominal surgery to help reduce gas buildup and stimulate the digestive system.
Choice D rationale
Drinking cold liquids is not specifically recommended for managing postoperative abdominal discomfort. However, staying hydrated is important
Correct Answer is D
Explanation
Choice A rationale
Absent bowel sounds are not a symptom of GERD. They may indicate a serious condition such as intestinal obstruction or ischemia.
Choice B rationale
An elevated temperature is not a symptom of GERD. It may indicate an infection or other medical condition.
Choice C rationale
A decreased ammonia level is not a symptom of GERD. It may be seen in conditions such as liver disease.
Choice D rationale
Pain relieved by taking antacids is a common symptom of GERD. Antacids work by neutralizing stomach acid, thereby relieving the burning sensation of heartburn.
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