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."

Answer and Explanation

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 is incorrect because lemon-glycerine swabs can be drying and irritating to the oral mucosa, which may exacerbate stomatitis symptoms. Instead, using a gentle, non-irritating lip balm or petroleum jelly is preferred.

Choice D option

"I should use a soft-bristle toothbrush to clean my teeth after meals." This response indicates an understanding of the teaching because a soft-bristle toothbrush is gentle on the gums and oral tissues, which is important for a client with stomatitis, as it helps to minimize irritation and injury.

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Correct Answer is A

Explanation

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.

B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.

C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.

D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

A. Natural loss of deciduous teeth B. Nontender, protruding abdomen C. Head circumference exceeds chest circumference D. Palpable fontanels

Correct Answer is B

Explanation

Choice A reason:

Natural loss of deciduous teeth is incorrect. Natural loss of deciduous teeth, also known as baby teeth, usually begins around the age of 5 or 6 years. At the age of 2, a toddler would still have their baby teeth.

Choice B reason:

This is a normal finding in toddlers. It is common for toddlers to have a protruding abdomen due to their body composition and the normal development of their abdominal muscles.

Choice C reason:

Head circumference exceeds chest circumference: In a typical 2-year-old toddler, the head circumference should be less than the chest circumference. The head grows rapidly during infancy and slows down as the child grows older, leading to a cage in the head-to-chest ratio.

Choice D reason:

The fontanels, or soft spots on the skull, usually close by the end of the first year. By age 2, the fontanels should be closed or very close to being closed, and they would not typically be palpable.

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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?

Nursing Test Bank

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Correct Answer is B

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