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 C

Explanation

Changing a central venous catheter dressing for a client who is receiving IV therapy. Sterile gloves are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected. A central venous catheter is inserted into a large vein near the heart and can be a source of infection if not handled properly. Changing the dressing requires sterile gloves to prevent contamination of the catheter site and the bloodstream.

A. Urinary frequency. B. Bleeding gums. C. Swelling of the face. D. Faintness upon rising.

Correct Answer is C

Explanation

The correct answer is choice c. Swelling of the face.

Choice A rationale:

Urinary frequency is a common symptom during pregnancy, especially in the first and third trimesters, due to hormonal changes and the growing uterus pressing on the bladder. It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination, which could indicate a urinary tract infection.

Choice B rationale:

Bleeding gums are also common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding. This condition, known as pregnancy gingivitis, is usually not serious but should be managed with good oral hygiene.

Choice C rationale:

Swelling of the face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs, often the kidneys. Preeclampsia typically occurs after 20 weeks of gestation but can develop earlier. It requires immediate medical attention to prevent complications for both the mother and the baby.

Choice D rationale:

Faintness upon rising, or orthostatic hypotension, is relatively common during pregnancy due to changes in blood circulation. It can usually be managed by rising slowly from a sitting or lying position. However, if fainting is frequent or severe, it should be discussed with a healthcare provider to rule out other underlying conditions.

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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

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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?