A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?
“I should gargle with an alcohol-based mouthwash to kill germs."
“I should limit my intake of dairy products to prevent nausea."
"I should moisten my lips with lemon-glycerine swabs."
“I should use a soft-bristle toothbrush to clean my teeth after meals."
The Correct Answer is D
Choice A reason:
"I should gargle with an alcohol-based mouthwash to kill germs”. This statement is not appropriate. Using an alcohol-based mouthwash is not recommended for a client with stomatitis. Alcohol can be irritating to the already inflamed mucous membranes and may worsen the condition. Instead, the client should use a mild, non-alcohol-based mouthwash or rinse as prescribed by the healthcare provider.
Choice B option
"I should limit my intake of dairy products to prevent nausea." This statement is not appropriate. While some clients may experience nausea during radiation therapy, limiting dairy products is not specifically related to stomatitis management. The client should follow any dietary recommendations provided by the healthcare provider or a registered dietitian to address nausea or other dietary concerns.
Choice C option
"I should moisten my lips with lemon-glycerine swabs." This statement is appropriate. Stomatitis is the inflammation of the mucous membranes in the mouth, which can occur as a side effect of radiation therapy. It can cause discomfort and dryness in the mouth, including the lips. Using lemon-glycerine swabs can help keep the lips moist and alleviate dryness.
Choice D option
"I should use a soft-bristle toothbrush to clean my teeth after meals. “This statement is not appropriate Using a soft-bristle toothbrush is an appropriate measure for oral care during stomatitis. It helps to minimize trauma to the sensitive oral tissues while still allowing for adequate dental hygiene. The client should brush their teeth gently after meals and follow any specific oral care instructions given by their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
Correct Answer is D
Explanation
A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.
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