A patient receiving chemotherapy for chronic myelocytic leukemia has irritates mucous membranes. Which of the following mouth care interventions would the nurse include in the plan of care?
Swab teeth and mucous membranes four times daily with lemon-glycerin swabs
Brush teeth twice a day with a firm toothbrush
Use sponge Toothettes to clean teeth between meals
Use waxed floss between meals and at bedtime
The Correct Answer is C
A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.
D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.
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Related Questions
Correct Answer is D
Explanation
A. Coffee is generally well tolerated unless the patient experiences discomfort or adverse effects from caffeine. It does not typically pose specific risks for patients with Hodgkin's disease.
B. Orange juice is generally safe to consume unless the patient has specific dietary restrictions or intolerances. It provides vitamin C and hydration.
C. Ginger ale is a non-caffeinated, carbonated beverage that is often used to alleviate nausea and upset stomach. It is generally safe to consume for patients with Hodgkin's disease unless there are individual sensitivities.
D. Alcohol consumption, including wine, should be avoided by patients with Hodgkin's disease, especially during treatment. Alcohol can suppress the immune system and may interact with medications or exacerbate side effects.
Correct Answer is C
Explanation
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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