The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

Encourage client to rinse the mouth twice a day with mouthwash

Encourage client to perform mouth care before and after every meal

Offer the client 3 meals per day with a snack at bedtime

Assess the client's oral pain level once a shift

Answer and Explanation

The Correct Answer is B

A. Rinsing the mouth with mouthwash is not sufficient for managing oral lesions, and some mouthwashes may contain alcohol that can further irritate the lesions; therefore, this intervention is inadequate.
B. Performing mouth care before and after every meal can help minimize discomfort, remove debris, and maintain oral hygiene, which is crucial for someone with painful oral lesions to encourage better nutritional intake.
C. Offering three meals with a bedtime snack may not be effective if the client is unable to eat comfortably; focusing on smaller, more frequent meals or nutrient-dense options may be more beneficial.
D. While assessing oral pain is important, it should occur more frequently than once per shift to ensure ongoing management and adjustment of care based on the client’s comfort and needs.

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Correct Answer is B

Explanation

A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratoryfunction, these parameters are not the most direct indicators of fluid volume status.

A. "You may feel some slight tingling in your lower extremities." B. "Paresthesia may occur because of the procedure, but it is only temporary." C. "The needle is placed between the vertebrae, but below where the spinal cord ends." D. "You should report any numbness during the procedure to the physician immediately."

Correct Answer is C

Explanation

A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.

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Electrolyte	Normal Value Range
Serum sodium	135-145 mEq/L
Serum chloride	97-107 mEq/L
Serum potassium	3.5-5:3 mEq/L
Serum magnesium	1.6-2.2 mg/dL
Total serum calcium	8.2-10.2 mg/dL
lonized calcium	4.6-5.3 mg/dL
Serum phosphorus	2.5-4.5 mg/dL
Serum osmolality	275-295 mOsm/kg
Urine osmolality	250-900 mOsm/kg

The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in the immediate postoperative period following a pancreatoduodenectomy (Whipple) procedure. The nurse is assessing for decreased fluid volume in the client. What would the nurse assess first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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