A nurse is caring for a client who has stomatitis following radiation therapy. Which of the following interventions is appropriate for the nurse to take?
Offer the client frozen banana as a snack.
Serve the client hot meals.
Avoid serving sauces or gravies.
Discourage the use of a straw.
The Correct Answer is A
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help soothe and cool the inflamed mucous membranes in the mouth and throat, which are caused by stomatitis. Stomatitis is an inflammation of the oral cavity that can result from radiation therapy or chemotherapy. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Checking gastric residuals every 8 hr is not frequent enough, as it can miss signs of delayed gastric emptying, which can cause aspiration, nausea, vomiting, or abdominal distension. Gastric residuals should be checked every 4 hr.
Choice B reason: Returning gastric contents if residual is less than 250 mL is not advisable, as it can increase the risk of infection, contamination, or electrolyte imbalance. Gastric contents should be discarded if residual is more than 100 mL.
Choice C reason: Measuring the pH of gastric residual every 24 hr is not necessary, as it does not reflect the effectiveness or tolerance of the feeding. The pH of gastric residual should be checked before each feeding or every 6 to 8 hr to confirm tube placement and prevent misconnection.
Choice D reason: Flushing the tube with 15 mL of water every 4 hr is a correct action, as it can prevent clogging, maintain patency, and clear the tube of formula residue. Water should also be used to flush the tube before and after each medication administration.
Correct Answer is D
Explanation
Choice A reason: Reporting ability to complete ADLs is not a specific finding that indicates that probiotic therapy is effective. Ability to complete ADLs depends on various factors, such as energy level, muscle strength, mobility, cognition, and motivation. Ability to complete ADLs may improve with parenteral nutrition, but not necessarily with probiotic therapy.
Choice B reason: Having pink mucous membranes is not a specific finding that indicates that probiotic therapy is effective. Pink mucous membranes reflect adequate hydration and oxygenation status, which are important for overall health, but not directly related to probiotic therapy.
Choice C reason: Having blood glucose level within the expected reference range is not a specific finding that indicates that probiotic therapy is effective. Blood glucose level is influenced by carbohydrate intake, insulin production, and medication use, which are related to parenteral nutrition, but not probiotic therapy.
Choice D reason: Having soft, formed bowel movements is a specific finding that indicates that probiotic therapy is effective. Probiotic therapy is the use of beneficial bacteria or yeast to restore the normal flora and function of the gastrointestinal tract, which can prevent or treat diarrhea, constipation, or infection. Having soft, formed bowel movements shows that the client has a healthy and balanced gut microbiome.
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