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?

Choice A reason: Place the client in a room near the elevator: This does **not** promote client safety, because it exposes the client to more noise and disturbance, which can increase stress and blood pressure. A quiet and calm environment is preferable for stroke clients.

Choice B reason: Complete a swallow study before giving anything by mouth: This **promotes** client safety, because it assesses the client's ability to swallow and prevent aspiration. Stroke clients may have impaired swallowing due to facial weakness or sensory loss.

Choice C reason: Provide a call button kept within reach: This **promotes** client safety, because it allows the client to communicate their needs and request assistance when needed. Stroke clients may have limited mobility or vision, which can increase their risk of falls or injuries.

Choice D reason: Initiate use of the bed alarm: This **promotes** client safety, because it alerts the staff if the client tries to get out of bed without assistance. Stroke clients may have impaired judgment or balance, which can lead to falls or accidents.

Choice E reason: Place client belongings out of reach: This does **not** promote client safety, because it makes the client feel frustrated and helpless. Stroke clients may have difficulty reaching for their belongings due to hemiparesis or hemiplegia, which can affect their self-care and independence. The nurse should place the client's belongings within reach on their unaffected side and encourage them to use them as much as possible.

Choice F reason: Instruct the client to call before getting up: This **promotes** client safety, because it ensures that the client has adequate support and supervision when getting up. Stroke clients may have orthostatic hypotension, which can cause dizziness or fainting when changing positions. The nurse should assist the client to get up slowly and monitor their vital signs.

For Potential Conditions:

The correct answer is c) Abdominal compartment syndrome.

Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.

Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.

The two actions the nurse should take to address abdominal compartment syndrome are:

• Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
• Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.

The two parameters the nurse should monitor to assess the client’s progress are:

• Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
• Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.