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A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?
- A. Assessing the client's oral cavity every 12 hours
- B. Ensuring that informed consent is on the chart
- C. Marking the client's bilateral pedal pulses
- D. Reviewing client teaching done previously
Correct Answer: A
Rationale: Mucositis can cause significant pain and discomfort, contributing to anorexia and weight loss. Assessing the client's oral cavity every 12 hours allows the nurse to monitor the severity of mucositis and implement interventions to improve nutrition and comfort.
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A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)
- A. Assist with rinsing the mouth with saline frequently.
- B. Encourage the client to eat room-temperature foods.
- C. Give the client hot liquids to hold in the mouth.
- D. Provide local anesthetic medications to swish and spit.
- E. Remind the client to brush gently after each meal.
Correct Answer: A,B,D,E
Rationale: Mucositis can interfere with nutrition. The nurse can help by assisting with rinsing the mouth frequently with saline, encouraging the client to eat cool or room-temperature foods, providing swish-and-spit anesthetics, and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids should be avoided as they can be painful for the client.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply the client's shoes before getting the client out of bed.
- B. Assist with ambulation.
- C. Shave the client with a safety razor only.
- D. Use a lift sheet to move the client up in bed.
- E. Use the Waterpik on a low setting for oral care.
Correct Answer: A,B,D
Rationale: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, and use a lift sheet when needed to reposition the client. An electric razor should be used instead of a safety razor, and a soft-bristled toothbrush is preferred over a Waterpik for oral care.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Reassuring clients that this change is temporary
- B. Referring clients to a reputable wig shop
- C. Teaching measures to prevent scalp injury
- D. Providing emotional support for body image changes
Correct Answer: D
Rationale: All actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.
A client tells the oncology nurse about an upcoming vacation to be back to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
- A. Are you ensuring the radiation site is protected?
- B. Do not expose the radiation area to direct sunlight.
- C. Have a wonderful time and enjoy your vacation!
- D. Remember you should not drink alcohol for a year.
Correct Answer: B
Rationale: The radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?
- A. Are you getting adequate rest and sleep each day?
- B. It is normal to be fatigued even for years afterward.
- C. This is a normal and I'll let the provider know.
- D. Try adding more vitamins B and C to your diet.
Correct Answer: B
Rationale: Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is a normal response.