A nurse is planning care for a client who is to undergo a stem cell transplant.

Which of the following actions should the nurse plan to take?

Rationale for correct condition: Mucositis is a common side effect of chemotherapy that causes inflammation and soreness in the mouth. The client reports mouth soreness and dry mucous membranes, consistent with mucositis. The presence of mild erythema on the oral mucosa also supports this diagnosis. Chemotherapy drugs such as vincristine and anthracycline are known to cause mucositis. Addressing mucositis early is crucial for maintaining the client’s nutrition and hydration.

Rationale for actions: Providing a soft sponge toothbrush helps maintain oral hygiene without causing further irritation. Maintaining the client’s diet ensures adequate nutrition, which is essential for healing mucositis. Pad the siderails of the bed is unnecessary in this scenario, as there's no indication of seizure risk. Requesting an antiemetic is irrelevant since the client has no significant nausea or vomiting.

Rationale for parameters: Monitoring weight loss helps assess the client’s nutritional status and the effectiveness of dietary interventions. Tracking intake and output ensures the client is adequately hydrated and that oral intake is sufficient. Edema monitoring is unnecessary, as there's no sign of fluid retention. Steatorrhea is not relevant in this context, as there's no indication of fat malabsorption.

Rationale for incorrect conditions: Diarrhea is not indicated as the client’s primary complaint is mouth soreness, not gastrointestinal upset. Angioedema is characterized by swelling and is not observed in the client. Seizures are not relevant here, as the client shows no neurological signs suggestive of seizure activity.

Choice A rationale
Administering IV opioids can help manage the intense pain associated with frostbite, improving patient comfort during rewarming and recovery.
Choice B rationale
After rewarming, the extremity should be elevated, not lowered, to reduce edema by encouraging fluid return to the central circulation.
Choice C rationale
Immersing hands and feet in warm water is a crucial step in the rewarming process, which helps restore blood flow and prevent further tissue damage.
Choice D rationale
Elevating affected limbs after rewarming helps reduce edema and prevents further swelling and complications.
Choice E rationale
Tetanus prophylaxis is recommended in frostbite cases as frostbite injuries can break the skin, increasing the risk of tetanus infection. Hence, avoiding tetanus prophylaxis is incorrect.