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

Answer and Explanation

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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Correct Answer is B

Explanation

A. While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B. A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C. While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D. A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.

A. BUN 11 mg/dL. serum creatinine 10 mg/dL B. BUN 45 mg/dL. serum creatinine 1.0 mg/dL C. BUN 35 mg/dL, serum creatinine 8 mg/dL D. BUN 10 mg/dL serum creatinine 0.3 mg/dL

Correct Answer is C

Explanation

A. These values are within the normal range and not indicative of chronic kidney disease.
B. While an elevated BUN is present, the serum creatinine level is within the normal range, which is not consistent with chronic kidney disease.
C. Both BUN and serum creatinine levels are elevated, indicating impaired kidney function and consistent with chronic kidney disease.
D. These values are within the normal range and not indicative of chronic kidney disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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