A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?

Correct Answer: C

Rationale: Rationale: Option C is correct because xerostomia (dry mouth) is a common side effect of radiation therapy to the head and neck area. It is important for the nurse to educate the client about this potential side effect and provide strategies for managing it. This includes encouraging the client to stay hydrated, suck on sugar-free candy, and avoid alcohol and tobacco. Option A is incorrect as lidocaine-containing mouthwash may not be appropriate for long-term use and may not effectively address the underlying issue of dry mouth. Option B is also incorrect as IV fluid boluses are not indicated for managing dry mouth. Option D is incorrect as assessing the client's neck for redness and swelling is not directly related to the client's complaint of dry mouth.

Correct Answer: C

Rationale: The correct answer is C. New onset shortness of breath is concerning for a pulmonary embolism, a serious complication of VTE. The nurse should act immediately to assess the patient's respiratory status and initiate appropriate interventions. A: Report of right calf pain is expected with VTE and does not require immediate action. B: Erythema of right lower leg can be a sign of inflammation but does not necessitate urgent intervention. D: Temperature of 100.4° F is a low-grade fever, which may indicate an infection but does not require immediate action in this context.

Correct Answer: D

Rationale: Step 1: Chronic stable angina is chest pain relieved by rest or nitroglycerin due to reduced blood flow to the heart. Step 2: Choice D indicates pain relieved by nitroglycerin, a hallmark of angina. Step 3: Choices A, B, and C do not specifically confirm angina diagnosis. Summary: Choice D is correct as it directly aligns with the characteristic relief of angina pain with nitroglycerin. Choices A, B, and C do not provide direct confirmation of chronic stable angina.

Correct Answer: C

Rationale: The correct answer is C because assessing the patient's intake, output, and daily weight provides direct information on fluid balance. Intake measures fluid coming in, output measures fluid going out, and daily weight reflects changes in total body water. Blood pressure and pulse (A) are affected by various factors and may not solely indicate fluid status. Serum potassium and sodium levels (B) are affected by multiple factors, not just fluid volume. Measurements of abdominal girth and calf circumference (D) are more specific to assessing for fluid retention in certain areas, not overall fluid volume status.

Correct Answer: C

Rationale: The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety. Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.