The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Encourage rinsing mouth twice a day with a sodium bicarbonate solution

Encourage client to perform mouth care before and after every meal

Assess oral pain level once a shift

Offer 3 meals per day with a snack at bedtime

Answer and Explanation

The Correct Answer is B

A. While mouth rinses can be helpful for some oral conditions, sodium bicarbonate solutions may not be appropriate for all types of oral lesions, and there are other more effective mouth care strategies for managing painful lesions.
B. This is a key intervention for managing painful oral lesions. Regular mouth care helps to maintain oral hygiene, reduce the risk of infection, and decrease discomfort while eating. It also promotes healing and prevents further complications.
C. While assessing pain is important, doing it just once a shift may not be sufficient. The nurse should assess pain more frequently, especially before and after meals, as pain from oral lesions can significantly impact a client’s ability to eat.
D. Offering small, frequent meals is typically more effective in improving nutrition for clients with painful oral lesions. The client may be more willing to eat smaller amounts rather than large meals, especially if pain is a significant issue.

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Correct Answer is B

Explanation

A. Waxed dental floss is generally safe for most patients, including those receiving chemotherapy. It is important to be gentle when flossing to avoid injuring sensitive gums, which may be more prone to bleeding during chemotherapy due to reduced platelet count.

B. Alcohol-based mouthwashes should be avoided during chemotherapy because they can cause dryness and irritation to the mucous membranes in the mouth, which are already sensitive due to the side effects of chemotherapy. Alcohol can exacerbate mucositis (inflammation of the mucous lining) and increase discomfort.

C. Soaking dentures in hydrogen peroxide is generally safe for denture care, as hydrogen peroxide can be used to disinfect dentures. However, it is important to ensure that dentures are thoroughly rinsed after soaking to avoid irritation to the mouth.

D. Using a soft-bristled toothbrush is safe and recommended. A soft-bristled toothbrush is ideal for patients receiving chemotherapy, as their gums and mouth may become more sensitive. Brushing gently can help maintain oral hygiene without causing injury.

A. platelet count of 50.000 B. nausea and vomiting C. temperature of 38.9 C (102F) D. alopecia

Correct Answer is C

Explanation

A. Platelet count of 50,000 is low (normal is usually 150,000-450,000), and this can be associated with bone marrow depression caused by chemotherapy. However, bone marrow depression itself doesn't cause a fever directly. The low platelet count increases the risk of bleeding, but it wouldn't necessarily lead to a temperature elevation by itself.

B. Nausea and vomiting are common side effects of chemotherapy but are not directly related to bone marrow depression. Bone marrow depression typically affects the production of blood cells (red blood cells, white blood cells, and platelets), but nausea and vomiting are more directly associated with the chemotherapy agents themselves rather than the resulting bone marrow suppression.

C. A fever of 38.9°C (102°F) could indicate an infection, which is a serious risk for patients with bone marrow depression due to chemotherapy. The suppression of white blood cell (WBC) production from chemotherapy leads to neutropenia, leaving the patient more vulnerable to infections. A fever in this context is a medical emergency and requires immediate attention, as it may signify a bacterial or fungal infection, which could be life-threatening in an immunocompromised patient.

D. Alopecia (hair loss) is a well-known side effect of chemotherapy, but it is not a direct consequence of bone marrow depression. It is more related to the chemotherapy drugs affecting rapidly dividing cells, like those in hair follicles. While it is a common and distressing symptom, it is not an indicator of bone marrow function or depression.

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The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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