A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Assess for signs of infection.

Assess for a patent airway.

Assess ability to clear oral secretions.

Assess for ability to communicate.

Answer and Explanation

The Correct Answer is B

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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Correct Answer is A

Explanation

Choice A reason:

A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.

Choice B reason:

Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.

Choice C reason:

Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.

Choice D reason:

Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.

A. "Don't worry, most clients dislike the prep more than the procedure itself." B. "After you have signed the consent form, we can talk more about this." C. "I know you're anxious, but this procedure is recommended for people your age." D. "Before the examination, your provider will give you a sedative that will make you sleepy."

Correct Answer is D

Explanation

- A: This response minimizes the client's feelings and may make them feel unheard. It's important for healthcare providers to acknowledge a patient's feelings and provide reassurance in a more empathetic manner.
- B: This response delays addressing the client's concerns and may increase his anxiety. Consent is important, but it should not be a barrier to discussing care and addressing concerns.
- C: This response is factual but does not address the client's immediate concern about pain. It's crucial to address the client's fears directly rather than deflecting to the procedure's necessity.
- D: This response directly addresses the client's concern about pain by informing him of the sedative, which is a common practice to reduce discomfort during a colonoscopy. It provides reassurance and factual information about the procedure's process.

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A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

Correct Answer is A

Explanation

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?

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