The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

The correct answers are Choice B and D:

Choice B: Report the appearance of the dressing to the charge nurse,

Choice D: Compress the drainage device before closing the tab.

Choice A rationale:

Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.

Choice B rationale:

Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.

Choice C rationale:

Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.

Choice D rationale:

Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.

Choice E rationale:

Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.

Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

The other options are not correct because:

A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.

B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.

D. Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.