A nurse is administering an intravenous antineoplastic drug to a client with cancer and recognizes that an extravasation is developing.
Which of the following actions should the nurse initiate first?

Choice A rationale

While anorexia and constipation can be side effects of some medications, they are not universally or primarily considered prominent long-term adverse effects specific to many modern antiretroviral therapies. Gastrointestinal intolerance can occur, but specific patterns like anorexia and constipation are not the most characteristic or significant chronic concerns associated with long-term ART.

Choice B rationale

Long-term antiretroviral therapy (ART) can lead to metabolic complications including bone demineralization, manifesting as osteopenia or osteoporosis, due to direct drug effects on bone metabolism and inflammatory processes. Oral thrush, a fungal infection, can occur as an opportunistic infection if ART is not fully effective, or as an independent issue.

Choice C rationale

A T-cell count of 500 cells/µL is considered within the normal range (500-1500 cells/µL) for adults and indicates effective immune reconstitution rather than an adverse effect of antiretroviral therapy. Diarrhea can be a common adverse effect, particularly with certain drug classes like protease inhibitors, but a T-cell count of 500 indicates therapeutic success.

Choice D rationale

Gastrointestinal intolerance, including nausea, vomiting, and diarrhea, is a common acute and sometimes persistent adverse effect of many antiretroviral drugs, especially during initiation. While neutropenia (normal range 1.5-8.0 × 10^9/L) can occur with some ART agents, it is not as universally prevalent or as defining a long-term issue as metabolic complications or persistent GI intolerance.

Choice A rationale

Assessing for increased calcium levels is not directly related to malnutrition in cancer patients. Malnutrition in cancer often involves deficits in various nutrients, and while electrolyte imbalances can occur, increased calcium is not a primary or universal indicator of malnutrition itself. It might be related to cancer processes like bone metastasis, but not the malnutrition specifically.

Choice B rationale

Encouraging mouth care before and after meals is crucial because it promotes oral hygiene and can improve the client's appetite and taste perception. Malnutrition often leads to oral discomfort, stomatitis, or altered taste, making food unappealing. Proper mouth care can alleviate these issues, thereby enhancing the client's willingness to eat and improving nutrient intake.

Choice C rationale

Advising the client to keep a food diary helps in accurately assessing their dietary intake. This objective record allows the nurse and other healthcare providers to identify patterns of consumption, quantify caloric and nutrient deficits, and tailor nutritional interventions more effectively. It provides valuable data for personalized care planning to address malnutrition.

Choice D rationale

Monitoring the client for changes in mental status is important because severe malnutrition, particularly deficiencies in certain vitamins (e.g., thiamine, B12) or significant electrolyte imbalances, can lead to neurological impairments. Altered mental status could indicate worsening nutritional status or complications requiring immediate intervention to prevent further deterioration.

Choice E rationale

Instructing the client to drink extra fluids between meals helps prevent early satiety that can occur if fluids are consumed with meals, which can reduce food intake. By consuming fluids between meals, the client can maintain hydration without compromising their ability to consume sufficient solid food, thus maximizing caloric and nutrient intake for malnutrition.