Clinical Nurse Leader Practice Exam

What should a nurse do first when a patient presents with sore throat after radiation treatment for lung cancer?

1. Assess the patient's oral mucosa for swelling and redness with ulcerations

2. Call the physician and obtain an order for antiseptic mouthwash

3. Instruct the patient to rinse her mouth before and after meals with salt and sodium bicarbonate

4. Use a soft-bristled toothbrush to clean her teeth and tongue

The correct answer is: Assess the patient's oral mucosa for swelling and redness with ulcerations

When a patient presents with a sore throat following radiation treatment for lung cancer, the first action a nurse should take is to assess the patient's oral mucosa for swelling, redness, and ulcerations. This assessment is crucial because radiation therapy can lead to mucositis, which is characterized by inflammation and ulceration of the mucous membranes in the mouth and throat. Identifying the extent and severity of mucosal damage allows the nurse to tailor subsequent interventions appropriately and prioritize care based on the patient's immediate needs. Understanding the condition of the oral mucosa also supports decisions regarding pain management, nutritional support, and possible referrals to specialists such as a dietitian or an otolaryngologist. By gathering pertinent assessment data first, the nurse ensures that any further actions taken, such as calling the physician for specific treatments or implementing oral hygiene protocols, are based on the current status of the patient, ultimately leading to better patient outcomes.