A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care?
Moisten the mucosa with lemon glycerin swabs.
Cleanse the gums with saline soaked gauze.
Administer oral viscous lidocaine.
Schedule routine oral care ever hr.
The Correct Answer is B
Choice A Reason:
Moisten the mucosa with lemon glycerin swabs. Lemon glycerin swabs might be too acidic and can cause irritation or discomfort in oral ulcers. Using them could exacerbate the toddler's condition.
Choice B Reason:
Cleanse the gums with saline-soaked gauze. This action can help maintain oral hygiene and reduce the risk of infection in the oral ulcers. Saline is gentle and can help keep the affected area clean without causing further irritation.
Choice C Reason:
Administer oral viscous lidocaine. Lidocaine is a local anesthetic that may be used in some cases for pain relief, but its use in oral ulcers for toddlers might not be recommended due to potential risks and concerns about ingestion, especially in young children.
Choice D Reason:
Schedule routine oral care every hour. While oral care is essential, performing it too frequently (every hour) might cause more discomfort and irritation to the already sensitive oral ulcers. Gentle, regular care is important, but excessive cleaning can be detrimental.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Acknowledge the family members' feelings of guilt. While it's important to validate the family's feelings and provide emotional support, assuming or acknowledging guilt without evidence could be harmful. Instead, the nurse should offer empathy and support without attributing blame.
Choice B Reason:
Discourage the parents from allowing siblings to view the body. The decision of whether siblings should view the body is personal and should be respected based on the family's beliefs and preferences. The nurse should offer guidance and support, allowing the family to make an informed decision.
Choice C Reason:
Avoid discussing details of the attempt to revive the infant. Discussing the attempt to revive the infant might help the family understand the medical interventions performed and the efforts made. However, it should be approached with sensitivity and based on the family's readiness to receive such information.
Choice D Reason:
Provide a follow-up phone call 1 week following the infant's death. Following up with the family after a week allows for ongoing support, assessment of their emotional well-being, and providing additional resources or guidance as needed during the grieving process.
Correct Answer is D
Explanation
Choice A Reason:
Encourage frequent physical activity to increase bone mass: While physical activity is generally beneficial for overall health, in the case of osteomyelitis, encouraging excessive or frequent physical activity might exacerbate pain, discomfort, and the risk of further bone injury. Controlled and appropriate physical activity may be recommended, but it should be individualized based on the child's condition and the affected area.
Choice B Reason:
Provide a high-calorie, low-protein diet: In osteomyelitis, a balanced and nutritious diet is important to support the child's overall health and aid in recovery. However, a high-calorie, low-protein diet would not be suitable for combating infection or supporting healing. Adequate protein intake is essential for tissue repair and immune function.
Choice C Reason:
Initiate contact precautions for the child: Osteomyelitis is not typically transmitted from person to person. It's an infection within the bone that doesn't require contact precautions for prevention of spread among individuals. Treatment primarily involves antibiotics and sometimes surgical drainage, but it doesn't necessitate isolation precautions.
Choice D Reason:
Maintain a patent intravenous catheter: Antibiotics are the mainstay of treatment for osteomyelitis, and they are usually administered intravenously for an extended period to effectively eradicate the infection. Maintaining a patent intravenous catheter ensures continuous access for medication administration.
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