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 ever hr.
The Correct Answer is B
Choice A Reason:
Moisten the mucosa with lemon glycerin swabs. Lemon glycerin swabs might be too acidic and can cause irritation or discomfort in oral ulcers. Using them could exacerbate the toddler's condition.
Choice B Reason:
Cleanse the gums with saline-soaked gauze. This action can help maintain oral hygiene and reduce the risk of infection in the oral ulcers. Saline is gentle and can help keep the affected area clean without causing further irritation.
Choice C Reason:
Administer oral viscous lidocaine. Lidocaine is a local anesthetic that may be used in some cases for pain relief, but its use in oral ulcers for toddlers might not be recommended due to potential risks and concerns about ingestion, especially in young children.
Choice D Reason:
Schedule routine oral care every hour. While oral care is essential, performing it too frequently (every hour) might cause more discomfort and irritation to the already sensitive oral ulcers. Gentle, regular care is important, but excessive cleaning can be detrimental.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Soak hairbrushes in boiling water for 10 minutes is incorrect. While it's good practice for general hygiene, impetigo is primarily a skin infection and is not typically spread through hairbrushes.
Choice B Reason:
Apply bactericidal ointment to lesions is correct. Topical antibiotics, such as mupirocin, are often recommended as treatment for impetigo. Applying bactericidal ointment to the lesions helps in the healing process and prevents the spread of the infection.
Choice C Reason:
Seal soft toys in a plastic bag for 14 days is incorrect. While cleaning and disinfecting toys is a good practice, impetigo is mainly transmitted through direct skin-to-skin contact or contact with contaminated items, but it does not require sealing toys in plastic bags for a specific duration.
Choice D Reason:
Administer acyclovir PO two times per day is incorrect. Acyclovir is an antiviral medication used to treat viral infections like herpes simplex virus (HSV), not bacterial infections like impetigo. It wouldn't be effective for impetigo treatment.
Correct Answer is C
Explanation
Correct answer: C
Choice A Reason:
Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.
Choice B Reason:
Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.
Choice C Reason:
Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.
Choice D Reason:
Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.
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