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.

Answer and Explanation

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.

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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.

A. Provide suctioning so the patient does not have to cough. B. Position the patient with the head of the bed elevated. C. Encourage the patient to take breaks from the oxygen mask every few hours. D. Ask the patient to do quick, shallow breaths. E. Teach the patient to cough at least once an hour. F. Avoid treating fever with antipyretics. G. Assist the patient in ambulating safely.

Correct Answer is ["B","E","G"]

Explanation

B. Position the patient with the head of the bed elevated. Rationale:

Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.

Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.

Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.

E. Teach the patient to cough at least once an hour. Rationale:

Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.

Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.

G. Assist the patient in ambulating safely. Rationale:

Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.

Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.

Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.

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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?

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Naxlex Comprehensive Predictor Exams

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

Correct Answer is C

Explanation

A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia. What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

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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?