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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Three or more consecutive premature ventricular contractions (PVCs) on an ECG tracing is indicative of ventricular tachycardia, a serious arrhythmia that requires prompt intervention.
B. Bigeminy refers to a pattern of every other beat being a PVC, not necessarily three or more consecutive PVCs.
C. Ventricular fibrillation is characterized by chaotic, disorganized ventricular activity on the ECG and is not defined by the presence of consecutive PVCs.
D. Trigeminy refers to a pattern of every third beat being a PVC, not necessarily three or more consecutive PVCs.
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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