a nurse is caring for a client who is receiving chemotherapy and has developed stomatitis which of the following actions should the nurse take
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

2. Which nursing action is a priority when managing a client with a wound infection?

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.

3. A healthcare professional is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the healthcare professional expect the provider to prescribe for the client?

Correct answer: C

Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage anxiety and prevent seizures during alcohol withdrawal. Haloperidol (Choice A) is an antipsychotic medication and is not typically used for alcohol withdrawal. Disulfiram (Choice B) is used in the treatment of alcohol use disorder but is not indicated for alcohol withdrawal. Phenobarbital (Choice D) may be used for alcohol withdrawal seizures but is not the first-line medication for managing alcohol withdrawal symptoms.

4. A client with asthma and a new prescription for an ipratropium inhaler is being taught by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D because waiting 1 minute between puffs ensures proper absorption of the medication. Choice A is incorrect as rinsing the mouth is not a specific instruction related to using the inhaler. Choice B is incorrect as waiting 5 minutes between puffs is longer than necessary. Choice C is incorrect as the timing of medication administration is not specified in the question.

5. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.

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