A patient receiving chemotherapy for chronic myelocytic leukemia has irritates mucous membranes. Which of the following mouth care interventions would the nurse include in the plan of care?
Swab teeth and mucous membranes four times daily with lemon-glycerin swabs
Brush teeth twice a day with a firm toothbrush
Use sponge Toothettes to clean teeth between meals
Use waxed floss between meals and at bedtime
The Correct Answer is C
A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.
D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dressings are typically not removed on the day of surgery to allow for observation of any bleeding or drainage. Dressing removal is usually performed by the surgical team or as directed by the healthcare provider.
B. Encourage ambulation on the day of surgery: Ambulation is important for preventing complications such as deep vein thrombosis and atelectasis, and to promote healing.
C. Postoperative positioning depends on the type of surgery performed and any specific patient needs, but placing the client in a supine position may not address comfort or respiratory considerations.
D. Offering ice cream, which is high in fat, may not be tolerated well immediately after this type of surgery.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should prioritize the client's immediate clinical needs based on the assessment data provided.
The first action should be to address the client's agitation, which is a sign of distress and can lead to safety issues. Therefore, the nurse should first address the client's "fall precautions" to ensure safety and prevent potential harm due to the client's disorientation and agitation.
Following this, the nurse should address the client's "urine collection" for urinalysis and culture and sensitivity (C&S), as it is critical to identify the cause of the client's febrile state and incontinence of foul-smelling urine, which could indicate an infection. This will allow for appropriate antibiotic therapy to be administered based on the sensitivity results.
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