A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Choice A reason:

Clean clothing is important for comfort and hygiene during a disaster, but it is not typically considered an essential item for a basic disaster preparedness kit. Essential items focus on survival needs such as food, water, and medical supplies.

Choice B reason:

Personal identification is crucial in a disaster situation. It helps in verifying identity, accessing services, and reuniting with family members. Important documents such as identification cards, insurance policies, and bank records should be included in a waterproof container.

Choice C reason:

The recommendation is to have one gallon of water per person per day for at least three days, which totals three gallons, not quarts. Water is essential for drinking and sanitation.

Choice D reason:

Matches can be useful for starting fires for warmth or cooking, but they are not considered a primary necessity in a basic disaster preparedness kit. More critical items include food, water, and medical supplies.

Choice E reason:

Prescription medications are essential for individuals who rely on them for chronic conditions. Having an adequate supply of necessary medications can be life-saving during a disaster when access to pharmacies may be limited.

Choice A reason: Tell the client to expect dark stools following chemotherapy

Dark stools are not a common side effect of chemotherapy. This symptom is more often associated with gastrointestinal bleeding or the use of certain medications, such as iron supplements or bismuth-containing compounds. Chemotherapy can cause a range of side effects, but dark stools are not typically one of them. Therefore, it is not necessary to inform the client to expect this symptom.

Choice B reason: Have the client swish with commercial mouthwash before therapy

While maintaining oral hygiene is important during chemotherapy, using a commercial mouthwash before therapy is not specifically recommended. Some commercial mouthwashes contain alcohol or other irritants that can exacerbate oral mucositis, a common side effect of chemotherapy. Instead, clients are often advised to use a gentle, alcohol-free mouthwash or a saline rinse to maintain oral hygiene and prevent infections.

Choice C reason: Administer an antiemetic prior to the procedure

Administering an antiemetic prior to chemotherapy is a standard practice to prevent nausea and vomiting, which are common side effects of many chemotherapeutic agents. Antiemetics help to improve the client’s comfort and adherence to the treatment regimen by reducing these distressing symptoms. This proactive approach is crucial in managing the side effects of chemotherapy and ensuring that the client can tolerate the treatment.

Choice D reason: Have the client floss 4 times daily

Flossing is an important part of oral hygiene, but flossing 4 times daily is excessive and can cause irritation or damage to the gums, especially in clients undergoing chemotherapy who may have a higher risk of oral mucositis and bleeding. It is generally recommended to floss once daily and to use a soft-bristled toothbrush to maintain oral health without causing additional trauma.