A patient undergoing chemotherapy reports painful oral ulcers, difficulty eating, and a metallic taste in the mouth. The nurse suspects stomatitis. Which nursing intervention is most appropriate for this patient?
Encourage the patient to use an alcohol-based mouthwash to clean the oral cavity.
Advise the patient to avoid all oral intake until the ulcers heal completely.
Suggest the patient to brush their teeth vigorously to remove any bacteria from the mouth
Recommend the patient to consume soft, non-irritating foods and avoid acidic or spicy foods.
The Correct Answer is D
A. Encourage the patient to use an alcohol-based mouthwash to clean the oral cavity:
Alcohol-based mouthwashes can irritate the oral mucosa and worsen the pain of stomatitis. Instead, non-alcoholic, soothing mouth rinses are recommended.
B. Advise the patient to avoid all oral intake until the ulcers heal completely: Patients still need proper nutrition, and complete avoidance of food can lead to malnutrition. Soft, non-irritating foods are encouraged rather than full avoidance.
C. Suggest the patient brush their teeth vigorously to remove any bacteria from the mouth: Vigorous brushing can worsen oral ulcers and lead to further pain and bleeding. A gentle, soft-bristle toothbrush should be recommended.
D. Recommend the patient to consume soft, non-irritating foods and avoid acidic or spicy foods.
Consuming soft, bland, non-irritating foods and avoiding acidic or spicy foods helps reduce discomfort and prevent further irritation of oral ulcers, which is essential in managing stomatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer intravenous antibiotics and observe the patient for 24 hours: IV antibiotics may be given preoperatively, but observation without surgery is not the standard treatment for confirmed appendicitis due to the risk of rupture.
B. Provide the patient with oral pain medications and discharge them with a follow-up appointment: Oral pain medications are not appropriate as the patient needs surgical intervention. Discharging the patient without surgery could result in life-threatening complications.
C. Recommend a liquid diet and bed rest to reduce inflammation: A liquid diet and bed rest will not address the underlying issue of appendicitis, which requires surgical removal of the inflamed appendix.
D. Prepare the patient for an appendectomy. The standard treatment for acute appendicitis is an appendectomy. Delaying surgery can lead to complications such as perforation, peritonitis, or abscess formation. This is the most appropriate intervention.
Correct Answer is A
Explanation
A. Measure abdominal girth daily. Measuring abdominal girth daily helps assess for changes in distention, which is important in monitoring the effectiveness of the decompression.
B. Moisten the client's lips with lemon-glycerin swabs: This is incorrect because lemon-glycerin swabs can dry the oral mucosa. Using plain water or normal saline swabs would be more appropriate.
C. Maintain the client in Fowler's position: This is appropriate as it helps promote drainage from the nasogastric tube and reduces the risk of aspiration.
D. Use sterile water to irrigate the nasogastric tube: Irrigation is typically done with normal saline to maintain electrolyte balance. Sterile water is not recommended for this purpose.
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