A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.

Choice A reason: Comparing the capillary refill in the hands is a useful assessment for evaluating peripheral circulation, but it is not specific to diagnosing carpal tunnel syndrome. Carpal tunnel syndrome involves compression of the median nerve, and capillary refill does not provide information about nerve compression.

Choice B reason: Determining the client's sleeping position may provide insight into factors that exacerbate symptoms, but it does not directly assess for carpal tunnel syndrome. While certain positions might worsen the condition, this information alone is not diagnostic.

Choice C reason: Applying firm pressure over the ulnar artery is not relevant to assessing carpal tunnel syndrome. The ulnar artery supplies blood to the hand, but carpal tunnel syndrome involves the median nerve, not the ulnar artery.

Choice D reason: Tapping the client's wrists to locate the pain, known as Tinel's sign, is a specific test for carpal tunnel syndrome. Tinel's sign is positive when tapping over the median nerve at the wrist elicits tingling or pain in the fingers, indicating nerve compression.