An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?​​​​​​

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

Stomatitis refers to the inflammation of the mouth and oral mucosa, which can cause pain and difficulty swallowing. In the context of a client receiving chemotherapy, stomatitis is a common side effect that can occur due to the effects of chemotherapy on rapidly dividing cells, including those in the oral cavity. When a client develops stomatitis, it is important for the practical nurse (PN) to obtain information about the client's ability to swallow during a focused assessment. This is because stomatitis can significantly impact a client's ability to eat and drink comfortably, which can lead to dehydration and malnutrition. Assessing the client's ability to swallow helps determine the extent of the issue and guides appropriate interventions and support.

Let's briefly evaluate the other options:

a) Urinary output.
Urinary output is not directly related to stomatitis. Stomatitis primarily affects the oral cavity, and its impact on urinary output is minimal or nonexistent. While monitoring urinary output is important for assessing hydration status, it is not the priority in this situation.

c) Frequency of bowel movements.
The frequency of bowel movements is unrelated to stomatitis. Stomatitis primarily affects the mouth, and its presence does not directly influence bowel movements. Assessing bowel movements may be relevant for other concerns, but it is not specifically related to stomatitis.

d) Blood pressure while standing.
Blood pressure while standing, also known as orthostatic blood pressure, is not directly relevant to stomatitis. Stomatitis primarily affects the oral cavity and does not typically have a direct impact on blood pressure. Assessing blood pressure while standing may be appropriate for other health concerns, such as orthostatic hypotension, but it is not the priority in this situation.

In summary, when a client receiving chemotherapy develops stomatitis, the practical nurse should focus on assessing the client's ability to swallow as it directly relates to the impact of stomatitis on the client's nutrition and hydration.