A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.
Which of the following actions should the nurse include in the plan of care?
Moisten the mucosa with lemon glycerin swabs.
Cleanse the gums with saline soaked gauze.
Administer oral viscous lidocaine.
Schedule routine oral care every 8 hr.
The Correct Answer is B
Choice A rationale:
Moisten the mucosa with lemon glycerin swabs is not recommended because lemon glycerin swabs can be acidic and may irritate the oral ulcers further. It's important to avoid irritating substances in the oral cavity to promote healing.
Choice B rationale:
Cleaning the gums with saline-soaked gauze is a gentle and non-irritating method to maintain oral hygiene for a toddler with oral ulcers. Saline solution helps keep the oral cavity clean and reduces the risk of infection without causing further irritation.
Choice C rationale:
Administering oral viscous lidocaine is not recommended for routine use in managing oral ulcers in children. Lidocaine can be absorbed systemically and lead to toxicity, especially in young children. It should only be used under the guidance of a healthcare provider and in specific circumstances where the benefits outweigh the risks.
Choice D rationale:
Scheduling routine oral care every 8 hours is important, but the method of oral care is equally crucial. Using gentle methods like saline-soaked gauze to clean the gums ensures proper hygiene without causing discomfort to the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The nurse does not need to report the heart rate as it falls within the normal range for a school-age child, which is typically between 70-100 beats per minute.
Choice B rationale:
The WBC count is 9,600/mm3, which is within the normal range for a school-age child (4,500 to 13,500/mm3) Therefore, this finding does not warrant reporting to the provider.
Choice C rationale:
HbA1c level is 8.5%, indicating poor blood sugar control. However, this finding is related to the child's cystic fibrosis and not an immediate concern. The nurse should address this issue but does not need to urgently report it to the provider.
Choice D rationale:
Oxygen saturation is 95%, which is within the normal range (typically 95-100%) However, for a child with cystic fibrosis who may have respiratory issues, a lower oxygen saturation level might be concerning. Therefore, the nurse should report this finding to the provider for further evaluation and intervention.
Correct Answer is B
Explanation
Choice A rationale:
Limb withdrawal is a pain response and indicates that the infant is experiencing pain. The goal of opioid pain medication is to alleviate pain, so limb withdrawal suggests inadequate pain control.
Choice B rationale:
A relaxed facial expression indicates that the infant is comfortable and not experiencing pain. It is a positive sign that the medication is having a therapeutic effect by providing pain relief.
Choice C rationale:
Increased blood pressure is not a typical response to opioid pain medication. Opioids often cause a decrease in blood pressure and can lead to hypotension.
Choice D rationale:
Bradycardia (slow heart rate) is not a common response to opioid pain medication. Opioids can cause respiratory depression and bradypnea (slow breathing), but they do not typically cause bradycardia.
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