Nokea
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
- A. Remove food debris from the teeth and oral mucosa with a stiff toothbrush.
- B. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth.
- C. Gargle and rinse the mouth several times a day with an antiseptic mouthwash.
- D. Rinse the mouth before and after each meal and at bedtime with a saline solution.
Correct Answer: D
Rationale: Head and neck radiation trashes the mouth ulcers and ropey saliva need saline rinses to clean gently, easing pain without wrecking tissue. Stiff brushes shred mucosa; peroxide burns it; antiseptic washes sting and dry. Nurses in oncology teach this saline's soothing, safe, and fights infection risk in a radiated, vulnerable mouth.
You may also like to solve these questions
Which of the following is FALSE regarding patient education for insulin therapy?
- A. It improves the patients experience and adherence to insulin therapy
- B. It requires time and preparation
- C. It can only be done by diabetes nurse educators
- D. Different topics and focus can be covered at different stages of insulin therapy
Correct Answer: C
Rationale: Insulin education boosts adherence and takes prep varied topics hit stages, and checking understanding's key. But pinning it to diabetes nurse educators alone flops; GPs, pharmacists, even peers can teach, widening reach. Team effort trumps solo specialty, ensuring chronic care's flexible, not bottlenecked, a practical truth in diabetes' long haul.
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?
- A. The UAP flushes the toilet once after emptying the patient's bedpan.
- B. The UAP stands by the patient's bed for 30 minutes talking with the patient.
- C. The UAP places the patient's bedding in the laundry container in the hallway.
- D. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.
Correct Answer: B
Rationale: Cervical implant's radioactive 30 minutes bedside overshoots exposure limits (under 30's safe); flushing , laundry , and mouthwash don't radiate. Nurses in oncology intervene UAP need time caps to dodge radiation, a safety must.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with end-stage kidney disease; pH 7.26; PaCO2 37 mm Hg; PaO2 94 mm Hg and HCO3 15 mEq/L. What do these values indicate?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: End-stage kidney disease hampers acid excretion pH 7.26 (below 7.35) and HCO3 15 mEq/L (below 22) confirm metabolic acidosis, as kidneys fail to buffer, dropping bicarbonate. PaCO2 37 mm Hg (normal) rules out respiratory issues lungs aren't compensating yet. PaO2 94 mm Hg shows oxygenation's fine. Alkalosis options contradict low pH; respiratory acidosis needs high CO2. Nurses recognize this acid-base shift, anticipating bicarbonate or dialysis, a key intervention in renal failure's metabolic chaos.
The family of a neutropenic client reports that the client is confused and 'is not acting right.' What action by the nurse is the priority?
- A. Delegate taking a set of vital signs
- B. Ask the client about pain
- C. Look at today's laboratory results
- D. Assess the client for a urinary tract infection
Correct Answer: A
Rationale: Neutropenia slashes immunity confusion screams infection, like sepsis, needing instant vitals to catch fever or shock, a priority delegated to flag danger fast per ABCs. Pain's a clue, but vitals trump. Labs lag; UTI assessment follows. Nurses lean on teamwork, ensuring rapid data in this infection-prone fog, a life-saving first step.
The nurse is working in the emergency department and has four clients arrive at the same time. Which client should the nurse see first?
- A. A client requesting antibiotics for a cough
- B. A client who has a facial fracture with severe facial and oral swelling
- C. A client who states she has not urinated in 8 hours
- D. A client with a history of chronic obstructive pulmonary disease reporting increased dyspnea
Correct Answer: B
Rationale: Facial fracture with severe swelling risks airway ABCs dictate first look, as edema could choke breathing fast. Cough's stable, anuria's concerning but not immediate, COPD dyspnea's chronic unless crashing. Nurses triage swelling, anticipating intubation, a split-second save in this ED rush.