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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.

Correct Answer is ["16"]

Explanation

To calculate the volume to be withdrawn from the vial, we need to follow these steps:

Convert the client's weight from pounds to kilograms:
- 110 lbs * (1 kg / 2.2 lbs) = 50 kg
Calculate the total dose of Vancomycin based on the prescribed dosage:
- 20 mg/kg * 50 kg = 1000 mg
Calculate the volume to be withdrawn from the vial:
- 1000 mg * (8 mL / 500 mg) = 16 mL

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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

The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Correct Answer is A

Explanation

A physician prescribes Vancomycin 20 mg/kg IV. The client weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial?

Correct Answer is ["16"]

Explanation

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