A client has returned from an extensive excision of a malignant oral tumor. On assessment, the nurse finds the client sitting in a high-Fowler position and complaining of jaw pain
The patient is dusky in color, but vital signs are within normal limits. The priority action by the nurse at this time is to a. assess oxygenation status by checking pulse oximetry and lung sounds.
b. call the physician and anticipate an order for an electrocardiogram (ECG).
c. have the client rate the pain and then administer the ordered pain medication.
d. remove the oral packing to assess the surgical incision.
A
After surgical excision of an oral tumor, clients may appear dusky because of venous congestion. The nurse needs to quickly ascertain if the dusky color is related to insufficient oxygenation by assessing lung sounds and pulse oximetry. Once normal oxygenation status is confirmed, the nurse can do a more detailed pain assessment and give pain medication.
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