You are caring for an 11-year-old girl with Acute Lymphoblastic Leukemia (ALL). She is inpatient receiving chemotherapy and has developed mucositis. Select which nursing interventions you would anticipate for this patient. Select THREE that apply.
Perform meticulous oral care with a hard bristled tooth brush.
Initiate NPO orders to minimize pain.
Administer a mouthwash with numbing and antibacterial agents.
Encourage a soft, bland diet and proper hydration
Monitor for rectal involvement and administer stool softeners.
Correct Answer : C,D,E
Rationale:
A. Perform meticulous oral care with a hard bristled toothbrush: A hard bristled toothbrush can easily damage the delicate and inflamed mucosa in a patient with mucositis, increasing pain, risk of bleeding, and potential entry points for infection. Using a soft-bristled toothbrush is safer.
B. Initiate NPO orders to minimize pain: Avoiding food altogether is generally not beneficial unless swallowing is unsafe, as it can lead to malnutrition and dehydration. Managing pain and modifying the diet is preferred so the patient can continue to receive nutrition and fluids.
C. Administer a mouthwash with numbing and antibacterial agents: These solutions help reduce discomfort during eating and oral care while lowering bacterial load in the mouth, which is important for infection prevention in immunocompromised patients.
D. Encourage a soft, bland diet and proper hydration: Soft, mild foods are less abrasive to oral tissues, and adequate fluid intake supports tissue healing and overall recovery. Eliminating rough, acidic, or spicy foods can help avoid worsening mucosal irritation.
E. Monitor for rectal involvement and administer stool softeners: Mucositis can affect the gastrointestinal tract beyond the mouth, leading to painful or fragile rectal mucosa. Stool softeners reduce the risk of trauma from straining during bowel movements, helping to prevent bleeding and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
• 402: The ANC (Absolute Neutrophil Count) is calculated by multiplying the total WBC count by the percentage of neutrophils (segs + bands) and then dividing by 100. Here, ANC = 2235 × (15 + 3)% = 2235 × 0.18 = approximately 402. This is below the critical threshold of 500, indicating neutropenia.
• Yes: Since the ANC is below 500, the patient is at high risk for infection and should be placed on neutropenic precautions to minimize exposure to pathogens and protect the immunocompromised patient.
Rationale for Inorrect Choices:
• 340: This value is too low to represent the ANC based on the given WBC and differential counts. It does not accurately reflect the neutrophil count in this case.
• 1000: This is above the typical neutropenia threshold of 500 cells/mm³ and thus would not indicate neutropenic precautions are needed. This answer does not match the calculation from the provided data.
• No: Given the ANC of 402, the patient is neutropenic, and standard precautions are insufficient to protect against infections in this immunocompromised state.
Correct Answer is A
Explanation
Rationale:
A. Acute Lymphoblastic Leukemia (ALL): ALL is the most common pediatric cancer, typically affecting children between the ages of 2 and 5. Clinical signs include pallor, fatigue, petechiae, recurrent fevers, and bone marrow suppression. A CBC often shows elevated WBCs with a predominance of immature lymphoblasts on a peripheral smear.
B. Hodgkin's Lymphoma: This cancer usually presents in older children and adolescents, often with painless cervical lymphadenopathy, night sweats, fever, and weight loss. It does not typically present with massive lymphoblast proliferation in peripheral blood, as seen in this case.
C. Acute Myelogenous Leukemia (AML): AML is more common in adults but can occur in children. It presents with similar symptoms of bone marrow failure but is characterized by myeloblasts rather than lymphoblasts on the blood smear.
D. Non-Hodgkin's Lymphoma: Pediatric non-Hodgkin's lymphoma often presents with rapidly enlarging lymph nodes, mediastinal mass, or abdominal symptoms. It is not primarily a bone marrow disease and would not typically show high lymphoblast counts in the peripheral blood.
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