A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

I will use a soft toothbrush or foam swab for oral care.

I will cleanse my mouth after meals with an alcohol-based mouthwash.

I will use a straw when I drink liquids.

I will rinse my mouth frequently with a hydrogen peroxide solution.

None

Answer and Explanation

The Correct Answer is B

Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.

Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.

Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.

Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.

Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.

Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.

Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.

A. Blood glucose using a glucometer B. Pupillary reaction to light C. Deep tendon reflexes D. Liver function laboratory values

Correct Answer is A

Explanation

Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.

Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.

Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.

Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.

View Question and Answer

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

A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?

Correct Answer is A

Explanation

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual course of MS. Which of the following responses should the nurse make?

A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care?

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend?

A nurse is caring for a male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)