The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first?
a. Document the size of the sores.
b. Perform mouth hygiene.
c. Have the client rinse his or her mouth.
d. Call the health care provider and hold chemotherapy.
D
Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hy-giene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important.
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