The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Encourage rinsing mouth twice a day with a sodium bicarbonate solution

Encourage client to perform mouth care before and after every meal

Assess oral pain level once a shift

Offer 3 meals per day with a snack at bedtime

Answer and Explanation

The Correct Answer is B

A. While mouth rinses can be helpful for some oral conditions, sodium bicarbonate solutions may not be appropriate for all types of oral lesions, and there are other more effective mouth care strategies for managing painful lesions.
B. This is a key intervention for managing painful oral lesions. Regular mouth care helps to maintain oral hygiene, reduce the risk of infection, and decrease discomfort while eating. It also promotes healing and prevents further complications.
C. While assessing pain is important, doing it just once a shift may not be sufficient. The nurse should assess pain more frequently, especially before and after meals, as pain from oral lesions can significantly impact a client’s ability to eat.
D. Offering small, frequent meals is typically more effective in improving nutrition for clients with painful oral lesions. The client may be more willing to eat smaller amounts rather than large meals, especially if pain is a significant issue.

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Correct Answer is B

Explanation

A. Respiratory rate, respiratory depth, and pulse oximetry is important for assessing respiratory status, especially postoperatively, but does not directly address fluid volume status, which is the priority nursing problem in this case.

B. After a pancreatoduodenectomy (Whipple procedure), patients are at risk for fluid imbalances due to potential complications such as leakage, infection, or inadequate gastrointestinal absorption. Monitoring abdominal girth, bowel sounds, and NG tube output helps assess fluid volume status and gastrointestinal function.

C. While BUN, creatinine, and weight are valuable in assessing kidney function and fluid status, the immediate postoperative concern is more focused on gastrointestinal function and fluid loss from surgical drainage, rather than renal function alone.

D. Vital signs and cardiac rhythm are important for monitoring overall cardiovascular status, but they do not specifically address the risk of deficient fluid volume as effectively as the assessments in option B, which directly address potential sources of fluid loss.

A. “I understand your fears. I was a smoker also.” B. "Don't worry. The important thing is you have now quit smoking." C. “It's okay to feel scared. Let's talk about what you are afraid of." D. “Your doctor is a great surgeon. You will be fine."

Correct Answer is C

Explanation

A. “I understand your fears. I was a smoker also.” This response shifts focus to the nurse's experience, which is not therapeutic or client-centered.
B. "Don't worry. The important thing is you have now quit smoking." This response dismisses the client’s emotional expression and minimizes her fear.
C. “It's okay to feel scared. Let's talk about what you are afraid of." This is the most therapeutic response. It validates the client’s feelings and encourages open communication.
D. “Your doctor is a great surgeon. You will be fine." This response is reassuring but dismissive, and it doesn't address the client’s expressed emotions.

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The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in the immediate postoperative period following a pancreatoduodenectomy (Whipple) procedure. A nursing problem of Risk for Deficient Fluid Volume has been assessed. What would be the priority nursing assessment?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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