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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.
Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.
Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.
Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².
Correct Answer is C
Explanation
Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.
Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.
Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.
Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.