A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Have the client floss 4 times daily.

Have the client swish with commercial mouthwash before therapy.

Tell the client to expect dark stools following chemotherapy.

Administer an antiemetic prior to the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason : Having the client floss 4 times daily is not typically recommended during chemotherapy because their gums may be more prone to bleeding due to a decrease in platelets, which is a common side effect of chemotherapy¹. Instead, gentle oral care is advised to prevent damage to the oral mucosa.

Choice B reason : Having the client swish with commercial mouthwash before therapy is not generally recommended because many commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes and may exacerbate chemotherapy-induced mucositis¹. Instead, a saline rinse or a prescribed mouthwash without alcohol may be used to help manage oral hygiene during chemotherapy.

Choice C reason : Telling the client to expect dark stools following chemotherapy could be misleading. While some chemotherapy drugs can cause changes in stool color, dark stools can also indicate gastrointestinal bleeding, which requires immediate medical attention¹. Therefore, patients should be instructed to report any significant changes in stool color to their healthcare provider.

Choice D reason : Administering an antiemetic prior to the procedure is a standard practice to prevent nausea and vomiting associated with chemotherapy¹. Antiemetics are medications that can help control these common side effects, improving the patient's comfort and ability to tolerate the treatment.

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Correct Answer is D

Explanation

Choice A reason : The statement is correct; even with sterile precautions, there is a risk of infection. It's important for clients to understand this risk and recognize signs of infection early¹.

Choice B reason : This statement is incorrect and indicates a misunderstanding. The volume of the output solution should be equal to or slightly less than the input solution due to fluid removal from the body¹.

Choice C reason : The fluid from the abdomen should indeed be clear or slightly yellow. Cloudy or discolored fluid can indicate an infection or other complication¹.

Choice D reason : Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution. The solution should be warmed to body temperature using a warming device designed for this purpose¹³.

A. Give morphine IV. B. Start an IV infusion of lactated Ringer's. C. Initiate cardiac monitoring. D. Administer oxygen therapy.

Correct Answer is D

Explanation

Choice A reason : While morphine IV can be used to alleviate pain and anxiety, it is not the first-line intervention for a pulmonary embolism. The primary concern in pulmonary embolism is to address the impaired gas exchange and potential hypoxemia¹.

Choice B reason : Starting an IV infusion of lactated Ringer's may be part of the overall management but is not the immediate priority. The initial focus should be on stabilizing the client's respiratory status¹.

Choice C reason : Initiating cardiac monitoring is important for observing the client's heart function, as pulmonary embolism can lead to strain on the heart. However, the first intervention should be to ensure adequate oxygenation¹.

Choice D reason : Administering oxygen therapy is the most critical initial intervention for a client with a pulmonary embolism. Oxygen therapy helps to manage hypoxemia and reduce the workload on the heart by improving oxygen saturation levels¹.

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A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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