A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.
Which of the following findings should the nurse identify as the priority?
Dysphagia.
Xerostomia.
Excoriation of the skin on the neck and chest.
Client reports a pain level of 6 on a scale from 0 to 10.
The Correct Answer is A
Choice A rationale:
Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.
Choice B rationale:
Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.
Choice C rationale:
Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.
Choice D rationale:
The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.
Choice B rationale:
Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.
Choice C rationale:
Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.
Choice D rationale:
Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Advance directives are voluntary and revocable; clients can change their decisions at any time as long as they are mentally competent.
Choice B rationale: Discussing advance directives with family ensures clarity, reduces future conflict, and supports informed decision-making aligned with the client’s wishes.
Choice C rationale: Witnesses are typically required, but a partner’s presence is not legally mandated unless designated as a healthcare proxy.
Choice D rationale: Notarization is not universally required; validity depends on state laws, and many jurisdictions accept signed and witnessed documents without attorney involvement.
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