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 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.
Correct Answer is B
Explanation
Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale
Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.
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