A client with emphysema reports difficulty breathing and exhibits audible wheezing.
The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Rationale for Choice A:

Direct (sliding) hiatal hernias: These are the most common type of hiatal hernia. They occur when the upper part of the stomach slides upward through the diaphragm into the chest cavity. This displacement disrupts the normal function of the lower esophageal sphincter (LES), which is a ring of muscle that acts as a valve between the esophagus and stomach. The LES is responsible for preventing stomach contents from refluxing back into the esophagus.

Esophageal reflux: When the LES is weakened or impaired, stomach acid, pepsin, and bile can flow back into the esophagus, causing a burning sensation known as heartburn, regurgitation of food or sour liquid, and irritation of the esophageal lining.

Prevention of esophageal reflux: Nursing actions aimed at preventing esophageal reflux are crucial in the management of hiatal hernias. These actions include:

Elevate the head of the bed: This helps to keep stomach contents below the level of the esophagus, reducing the risk of reflux. Avoid eating large meals: Large meals put more pressure on the stomach, which can increase the likelihood of reflux.

Avoid lying down after eating: Lying down can allow stomach contents to flow back into the esophagus more easily. Avoid foods that trigger reflux: Common triggers include fatty foods, spicy foods, acidic foods, caffeine, and alcohol.

Maintain a healthy weight: Excess weight can increase abdominal pressure and contribute to reflux.

Consider medications: If lifestyle changes are not enough to control reflux, medications such as antacids, H2 blockers, or proton pump inhibitors may be prescribed.

Rationale for Choice B:

Maintaining intact oral mucosa: This is not a primary goal in the care of a client with a hiatal hernia. While oral hygiene is important for overall health, it does not directly address the issue of esophageal reflux.

Rationale for Choice C:

Increasing intestinal peristalsis: This is not a relevant goal for a hiatal hernia. Hiatal hernias primarily affect the upper digestive tract, not the intestines.

Rationale for Choice D:

Promoting effective swallowing: This is not the most important goal in the care of a client with a hiatal hernia. While swallowing difficulties can occur in some cases, they are not the primary concern. The priority is to prevent esophageal reflux and its associated complications.

Choice A rationale:

Sterile gloves are not necessary for routine oral care, even in the presence of oral Candida albicans.

Standard precautions, which include the use of gloves, are sufficient to protect the UAP from exposure to blood and body fluids.

Sterile gloves would only be indicated for invasive procedures, such as oral surgery or deep tissue sampling.

Choice B rationale:

Delegating oral care to the UAP is appropriate, as it is a routine task that does not require the specialized skills of a nurse.

The nurse should provide clear instructions to the UAP on how to perform oral care, but it is not necessary for the nurse to complete the task themselves.

Choice C rationale:

Using a soft-bristled toothbrush is important for patients with oral Candida albicans, as it can help to remove plaque and debris without further irritating the delicate tissues of the mouth.

A soft-bristled toothbrush is less likely to cause bleeding or pain than a harder-bristled toothbrush.

Choice D rationale:

Mouthwash is not typically recommended for patients with oral Candida albicans, as it can actually dry out the mouth and worsen symptoms.

In some cases, a healthcare provider may prescribe a special antifungal mouthwash, but this should only be used under their supervision.