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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Free Nursing Study Resources

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.

A. Regular rapid heartbeat. B. Increased anxiety. C. Uncontrollable shaking. D. Throat irritation.

Correct Answer is C

Explanation

Choice A rationale:

A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.

Choice B rationale:

Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.

Choice C rationale:

Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:

Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely

Administering medications to counteract the tremors, such as beta-blockers, if ordered

Choice D rationale:

Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is C

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?