A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Be alert for non-verbal clues for pain or discomfort

Answer for the client during rounds with the physician

Assessment of the ability to cough and swallow

Provide enough time for the client to respond

Answer and Explanation

The Correct Answer is C

A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.

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Correct Answer is ["62.5"]

Explanation

To determine the IV pump rate, we need to calculate the flow rate in milliliters per hour (mL/h).

Given:

Total volume: 500 mL
Infusion time: 8 hours

Calculation:

Flow rate = Total volume / Infusion time
Flow rate = 500 mL / 8 hours
Flow rate = 62.5 mL/h

A. using a 23 gauge 1/2 inch needle for subcutaneous insulin. B. monitoring the skin for dryness at injection site. C. reporting multiple consecutive blood glucose levels over 200 mg/dL. D. emphasizing the need to get eyes checked every 3 months.

Correct Answer is C

Explanation

A. While using the correct needle size is important for insulin administration, it is not the most critical aspect of discharge planning. The focus should be on managing blood glucose levels and recognizing when medical intervention is needed.
B. Monitoring the skin for dryness at the injection site is a good practice, but it is not the most urgent issue to address in discharge planning for a newly diagnosed diabetic client.
C. Consistently elevated blood glucose levels above 200 mg/dL may indicate poor control of diabetes and require prompt adjustments in treatment. Teaching the client to recognize and report hyperglycemia is essential to prevent complications such as diabetic ketoacidosis (DKA).
D. Eye exams are important for long-term diabetes management to monitor for diabetic retinopathy, but every 3 months is excessive. Annual eye exams are typically sufficient unless otherwise indicated by the healthcare provider.

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A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive 500 mL of IV fluid over 8 hours. At what rate should the nurse set the IV pump?

Correct Answer is ["62.5"]

Explanation

The nurse is performing discharge planning for a client newly diagnosed with type 1 diabetes mellitus. It would be most important for the plan to include:

Correct Answer is C

Explanation

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