A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

Choice A reason: Placing the chin down and tilting the head for dysphagia (difficulty swallowing) during meals is not directly related to managing mucositis. While it may help with swallowing difficulties, it does not address the inflammation and pain caused by mucositis.

Choice B reason: Normal saline mouth rinses as swish and spit after meals and bedtime is an effective intervention for managing mucositis. Rinsing with saline helps to keep the mouth clean, reduce bacterial load, and soothe inflamed tissues. It can also help to remove food particles and debris, reducing the risk of infection and promoting healing. Saline rinses are gentle and do not contain irritating ingredients, making them ideal for sensitive oral tissues affected by mucositis.

Choice C reason: Eating high caloric meals to prevent weight loss is important for overall nutrition, especially for clients undergoing cancer treatment. However, it does not specifically address the management of mucositis. High caloric meals alone will not alleviate the pain, inflammation, and ulceration associated with mucositis. Clients with mucositis often have difficulty eating due to pain, so focusing on soothing and healing the oral tissues is a priority before addressing caloric intake.

Choice D reason: Using a commercial mouthwash for xerostomia (dry mouth) is not recommended for managing mucositis. Many commercial mouthwashes contain alcohol and other harsh ingredients that can further irritate the already inflamed mucous membranes. It is better to use a gentle and soothing rinse, such as saline, to manage mucositis symptoms and promote healing of the oral tissues.

Choice A reason: Encouraging deep breathing and coughing exercises is generally important postoperatively to prevent respiratory complications. However, it is not specific to eye surgery and does not address the immediate care needs following the removal of glass from the eye.

Choice B reason: Obtaining vital signs every 2 hours during hospitalization is a standard postoperative procedure to monitor for complications. While important, it is not an intervention specific to eye surgery and does not directly address the protection and care of the operated eye.

Choice C reason: Providing an eye shield to be worn while sleeping is a crucial intervention immediately following eye surgery. The eye shield protects the operated eye from accidental injury, rubbing, or pressure during sleep. This helps to prevent complications and promotes healing by keeping the eye safe from potential harm while the client is unaware.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing postoperative care. However, it is not the immediate priority following the surgery. The first step is to ensure the protection of the eye, which can be achieved by providing an eye shield. Teaching about eye drop administration can be done later as part of the discharge instructions.