Hesi Med Surg
Hesi Med Surg ( 34 Questions)
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
Cleaning the tongue and mouth with swabs is not the best initial nursing action, as it can cause more irritation and pain to the mucous membranes. Swabs can be abrasive and harsh on the inflamed and ulcerated tissues. The client should use a soft toothbrush or a sponge to gently clean the tongue and mouth, and avoid alcohol-based mouthwashes or rinses.
Administering a topical analgesic per protocol is the best initial nursing action, as it can provide immediate relief and comfort to the client. Topical analgesics can numb the nerve endings and reduce the sensation of pain in the tongue and mouth. The client should follow the health care provider's instructions on how to apply the analgesic, and avoid eating or drinking for at least 30 minutes after the application.
Obtaining a soft diet for the client is a correct nursing action, but not the best initial one, as it can help prevent further trauma and damage to the mucous membranes. A soft diet consists of foods that are easy to chew and swallow, such as soups, puddings, yogurts, and mashed potatoes. The client should avoid foods that are spicy, acidic, salty, or hard, such as citrus fruits, tomatoes, chips, and nuts.
Encouraging frequent mouth care is a correct nursing action, but not the best initial one, as it can help prevent infection and promote healing of the mucous membranes. Frequent mouth care involves rinsing the mouth with water or saline solution several times a day, especially after meals and before bedtime. The client should also keep the lips moist with a lip balm or petroleum jelly.
Choice A reason: Cleaning the tongue and mouth with swabs is not the best initial nursing action, as it can cause more irritation and pain to the mucous membranes. Swabs can be abrasive and harsh on the inflamed and ulcerated tissues. The client should use a soft toothbrush or a sponge to gently clean the tongue and mouth, and avoid alcohol-based mouthwashes or rinses.
Choice B reason: Administering a topical analgesic per protocol is the best initial nursing action, as it can provide immediate relief and comfort to the client. Topical analgesics can numb the nerve endings and reduce the sensation of pain in the tongue and mouth. The client should follow the health care provider's instructions on how to apply the analgesic, and avoid eating or drinking for at least 30 minutes after the application.
Choice C reason: Obtaining a soft diet for the client is a correct nursing action, but not the best initial one, as it can help prevent further trauma and damage to the mucous membranes. A soft diet consists of foods that are easy to chew and swallow, such as soups, puddings, yogurts, and mashed potatoes. The client should avoid foods that are spicy, acidic, salty, or hard, such as citrus fruits, tomatoes, chips, and nuts.
Choice D reason: Encouraging frequent mouth care is a correct nursing action, but not the best initial one, as it can help prevent infection and promote healing of the mucous membranes. Frequent mouth care involves rinsing the mouth with water or saline solution several times a day, especially after meals and before bedtime. The client should also keep the lips moist with a lip balm or petroleum jelly.