A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?
Have the client floss 4 times daily.
Have the client swish with commercial mouthwash before therapy.
Tell the client to expect dark stools following chemotherapy.
Administer an antiemetic prior to the procedure.
The Correct Answer is D
Choice A reason : Having the client floss 4 times daily is not typically recommended during chemotherapy because their gums may be more prone to bleeding due to a decrease in platelets, which is a common side effect of chemotherapy¹. Instead, gentle oral care is advised to prevent damage to the oral mucosa.
Choice B reason : Having the client swish with commercial mouthwash before therapy is not generally recommended because many commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes and may exacerbate chemotherapy-induced mucositis¹. Instead, a saline rinse or a prescribed mouthwash without alcohol may be used to help manage oral hygiene during chemotherapy.
Choice C reason : Telling the client to expect dark stools following chemotherapy could be misleading. While some chemotherapy drugs can cause changes in stool color, dark stools can also indicate gastrointestinal bleeding, which requires immediate medical attention¹. Therefore, patients should be instructed to report any significant changes in stool color to their healthcare provider.
Choice D reason : Administering an antiemetic prior to the procedure is a standard practice to prevent nausea and vomiting associated with chemotherapy¹. Antiemetics are medications that can help control these common side effects, improving the patient's comfort and ability to tolerate the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Acting as if the hallucination is real can validate the client's false perceptions and potentially reinforce the hallucination. It is important to maintain a sense of reality and not to enter into the client's hallucinatory experience.
Choice B reason : Instructing the client to argue with the voices is not therapeutic. It can increase the client's agitation and anxiety, and it does not help in distinguishing reality from hallucinations.
Choice C reason : While it is important to understand the client's experience, asking direct questions about the hallucination may lead the client to focus more on the hallucination, which can reinforce its presence. The nurse should focus on reality-based topics.
Choice D reason : This is the correct action. The nurse should gently and firmly reassure the client that the hallucination is not real and is a symptom of their illness. This helps to orient the client to reality and can reduce the distress associated with hallucinations.
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.
Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.
Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.
Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.
Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.
Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.
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