An adult patient is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the patient.
Which instruction should the nurse give to the UAP?
Wear sterile gloves when cleansing any areas of infected mucosa.
Assist with personal care, but leave oral care for the nurse to complete.
Provide a soft-bristled toothbrush for the patient to use during oral care.
Offer the patient mouthwash for thorough cleansing after brushing teeth.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The most likely diagnosis for this client isB. Pulmonary embolism and postpartum hemorrhage.
Here’s why:
- Postpartum Hemorrhage:
- The client has a large amount of lochia rubra, indicating significant blood loss.
- Hemoglobin and hematocrit levels are low (7.5 g/dL and 22%, respectively), which is consistent with significant blood loss.
- Symptoms like feeling lightheaded, pale appearance, and cool, clammy skin further support this diagnosis.
- Pulmonary Embolism:
- The client is experiencing shortness of breath, using accessory muscles to breathe, and has an oxygen saturation of 88% on room air.
- Elevated D-dimer levels (1.5 µg/mL) suggest the presence of a clot.
- Arterial Blood Gas (ABG) results show a low PaO2 (60 mmHg) and a slightly acidic pH (7.32), which can be seen in pulmonary embolism.
- The client reports a feeling of tightness in her chest and has a rapid heart rate (120 beats per minute), which are also indicative of a pulmonary embolism.
Correct Answer is C
Explanation
Choice A rationale:
Carbon dioxide is primarily eliminated through the lungs, not the kidneys. While the kidneys do play a role in acid-base balance, their primary mechanism for regulating pH is through the excretion or retention of bicarbonate ions (HCO3-), not carbon dioxide itself.
The kidneys' ability to compensate for respiratory acidosis is limited. In cases of severe respiratory acidosis, the kidneys may not be able to adequately compensate, leading to a further decrease in blood pH.
Choice B rationale:
Hyperventilation would actually decrease carbon dioxide levels in the blood, not increase them. Hyperventilation is a state of rapid, deep breathing that leads to increased exhalation of carbon dioxide. This can result in respiratory alkalosis, which is the opposite of respiratory acidosis.
Choice D rationale:
Low blood oxygen levels (hypoxia) can stimulate respiration, but this would not directly cause respiratory acidosis. In fact, hypoxia can sometimes lead to respiratory alkalosis due to hyperventilation.
Respiratory acidosis is primarily caused by impaired carbon dioxide elimination, not decreased oxygen levels.
Choice C rationale:
High levels of carbon dioxide in the blood (hypercapnia) are the hallmark feature of respiratory acidosis. This can occur due to a variety of factors that impair ventilation, such as:
Chronic obstructive pulmonary disease (COPD) Asthma
Pneumonia Sleep apnea
Neuromuscular disorders that affect breathing Drug overdose (e.g., opioids)
The accumulation of carbon dioxide in the blood leads to a decrease in blood pH, which can have a range of negative effects on the body's organ systems.
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