A nurse assesses a client's oral cavity and observes the ...

[rl]

A nurse assesses a client's oral cavity and observes the condition depicted in the photo below:
 
  What action by the nurse is best?
  a.
  Ask about the client's human immunodeficiency virus (HIV) status.
  b.
  Assess the client for dysphagia.
  c.
  Listen to the client's lung sounds.
  d.
  Refer the client to an oncologist.

Question 2

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority?
 
  a. Delegate oral care every 4 hours.
  b. Monitor and record the client's intake.
  c. Place the client in a high-Fowler's position.
  d. Remove the inner cannula for cleaning.

[zogaridan]

Answer to Question 1

ANS: B
This client has oral candidiasis. If the infection extends down the pharynx, the client could have difficulty swallowing. Therefore, the nurse should assess the client for dysphagia. HIV status may or may not be related but is not the priority. Listening to the lungs is unrelated. Since oral candidiasis is an infectious condition, referral to an oncologist is not needed.

Answer to Question 2

ANS: C
To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula.

[rl]

Excellent

[matt95]

TYSM