The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis.
Which information should the PN obtain from the client during a focused assessment?
Urinary output.
Ability to swallow.
Frequency of bowel movements.
Blood pressure while standing.
The Correct Answer is B
Stomatitis refers to the inflammation of the mouth and oral mucosa, which can cause pain and difficulty swallowing. In the context of a client receiving chemotherapy, stomatitis is a common side effect that can occur due to the effects of chemotherapy on rapidly dividing cells, including those in the oral cavity. When a client develops stomatitis, it is important for the practical nurse (PN) to obtain information about the client's ability to swallow during a focused assessment. This is because stomatitis can significantly impact a client's ability to eat and drink comfortably, which can lead to dehydration and malnutrition. Assessing the client's ability to swallow helps determine the extent of the issue and guides appropriate interventions and support.
Let's briefly evaluate the other options:
a) Urinary output.
Urinary output is not directly related to stomatitis. Stomatitis primarily affects the oral cavity, and its impact on urinary output is minimal or nonexistent. While monitoring urinary output is important for assessing hydration status, it is not the priority in this situation.
c) Frequency of bowel movements.
The frequency of bowel movements is unrelated to stomatitis. Stomatitis primarily affects the mouth, and its presence does not directly influence bowel movements. Assessing bowel movements may be relevant for other concerns, but it is not specifically related to stomatitis.
d) Blood pressure while standing.
Blood pressure while standing, also known as orthostatic blood pressure, is not directly relevant to stomatitis. Stomatitis primarily affects the oral cavity and does not typically have a direct impact on blood pressure. Assessing blood pressure while standing may be appropriate for other health concerns, such as orthostatic hypotension, but it is not the priority in this situation.
In summary, when a client receiving chemotherapy develops stomatitis, the practical nurse should focus on assessing the client's ability to swallow as it directly relates to the impact of stomatitis on the client's nutrition and hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Procure platelet products from the blood bank. Rationale: Procuring platelet products from the blood bank is a specialized task that requires specific training and authorization. It should be performed by licensed healthcare providers, such as nurses or physicians, rather than unlicensed assistive personnel (UAP).
Choice B rationale:
Titrate oxygen to the prescribed parameters. Rationale: Titrating oxygen to prescribed parameters requires clinical judgment and assessment skills, which are beyond the scope of practice for UAP. This task should be performed by licensed nurses or respiratory therapists.
Choice C rationale:
Monitor an intravenous infusion rate on an established schedule. Rationale: This is the correct answer. UAP can be trained to monitor intravenous (IV) infusion rates on an established schedule for clients who do not require complex adjustments. It is within their scope of practice to ensure that the IV is running at the prescribed rate and to report any abnormalities or concerns to the nursing staff.
Choice D rationale:
Insert a urinary catheter for an uncomplicated client. Rationale: Inserting a urinary catheter is a specialized nursing procedure that should only be performed by licensed nurses or healthcare providers. It is not within the scope of practice for UAP, even for uncomplicated cases.
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A rationale:
Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise1. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.
Choice B rationale:
Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.
Choice C rationale:
Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis1.
Choice D rationale:
Hypokalemia is not a symptom of DKA. In fact, patients with DKA often have high potassium levels in their blood at presentation because acidosis causes potassium to move from inside the cells into the bloodstream1. However, during treatment for DKA, when insulin is administered and acidosis is corrected, potassium moves back into the cells and can lead to low potassium levels or hypokalemia1.
Choice E rationale:
Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.
Choice F rationale:
Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.
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