A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

I will use a soft toothbrush or foam swab for oral care.

I will cleanse my mouth after meals with an alcohol-based mouthwash.

I will use a straw when I drink liquids.

I will rinse my mouth frequently with a hydrogen peroxide solution.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.

Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.

Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.

Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.

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Correct Answer is A

Explanation

Choice A reason: This is the correct information, because pursed-lip breathing can help improve gas exchange by creating positive pressure in the airways, preventing air trapping and alveolar collapse, and increasing the exhalation time.

Choice B reason: This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.

Choice C reason: This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.

Choice D reason: This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.

A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

Correct Answer is B

Explanation

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Correct Answer is B

Explanation

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