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

A. Check the client's condition after the procedure. B. Assist the client to ambulate for the first time following the procedure. C. Witness the client's signature on the consent for the procedure. D. Give the client atropine 30 min before the procedure.

Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Checking the client’s condition after the procedure involves assessment, which is a critical component of the nursing process. This task requires clinical judgment and knowledge of potential complications, which are responsibilities that cannot be delegated to assistive personnel.

Choice B reason: Assisting with ambulation is a task that can be safely delegated to assistive personnel. It is a basic care task that does not require clinical judgment and can be performed under the supervision of a nurse.

Choice C reason: Witnessing a client’s signature on the consent for the procedure is a legal and ethical responsibility that involves ensuring the client understands the procedure and is giving informed consent. This task requires a level of professional accountability that is beyond the scope of assistive personnel.

Choice D reason: Administering medication, such as atropine 30 minutes before the procedure, is a nursing intervention that requires knowledge of pharmacology and the ability to monitor for adverse effects. This is not within the scope of practice for assistive personnel and must be performed by licensed nursing staff.

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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?

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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?