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.

Answer and Explanation

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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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.

Choice B rationale:

A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.

Choice C rationale:

Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.

Choice D rationale:

Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.

A. Instruct the client to abstain from sexual intercourse for 1 month. B. Administer ceftriaxone via intermittent IV bolus. C. Schedule the client for retesting in 1 week. D. Report the infection to the state department of health.

Correct Answer is D

Explanation

Choice A rationale:

Instructing the client to abstain from sexual intercourse for one month is not necessary for the management of Chlamydia trachomatis. Instead, the client should be advised to abstain from sexual activity until they and their partner(s) have completed the prescribed course of antibiotics and are no longer contagious, which is usually within 7 days.

Choice B rationale:

Administering ceftriaxone via intermittent IV bolus is not the recommended route for treating Chlamydia trachomatis. The standard treatment for Chlamydia trachomatis infection is oral antibiotics, such as azithromycin or doxycycline. Intravenous administration is not typically required for uncomplicated cases.

Choice C rationale:

Scheduling the client for retesting in one week is not necessary if the client has received appropriate treatment and follows the prescribed course of antibiotics. Retesting is generally recommended 3 months after treatment, especially in cases of persistent or recurrent symptoms.

Choice D rationale:

Reporting the infection to the state department of health is a crucial action. Chlamydia trachomatis is a reportable sexually transmitted infection in many jurisdictions. Reporting helps public health authorities track the incidence of the disease, implement preventive measures, and allocate resources effectively to control its spread within the community. It is essential for the nurse to comply with legal and ethical obligations by reporting the infection to the appropriate health authorities.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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?