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 D
Explanation
Choice D rationale:
Highlights daily use: Tiotropium is a long-acting bronchodilator, meaning it works to relax and open the airways over an extended period. It's crucial for managing COPD symptoms and preventing exacerbations. Daily use is essential to maintain its effectiveness.
Emphasizes the Handihaler: The Handihaler is the specific inhalation device designed for tiotropium delivery. It ensures proper medication administration and optimal lung deposition.
Demonstrates understanding of instructions: Choosing this option indicates the client has correctly grasped the intended frequency and method of use.
Choice A rationale:
Misunderstanding of purpose: Tiotropium is not a rescue inhaler for sudden shortness of breath. It's a maintenance medication that works gradually to improve lung function. For acute symptoms, a short-acting bronchodilator, like albuterol, is required.
Potential delay in appropriate treatment: Reliance on tiotropium for acute episodes could lead to delayed use of the correct rescue medication, potentially worsening symptoms and increasing risks.
Choice B rationale:
Potential side effect, not primary goal: While tiotropium may reduce sputum thickness in some individuals, it's not the primary aim of therapy. Focusing on this aspect could overlook its broader benefits in managing COPD.
Variable response: The extent of sputum thinning varies among individuals and shouldn't be the sole indicator of effectiveness.
Choice C rationale:
Potential for overmedication: Using multiple inhalers without clear guidance from a healthcare provider could increase the risk of excessive medication and adverse effects.
Importance of individualized regimens: Inhaler use depends on the specific medications prescribed and the severity of COPD. Healthcare professionals tailor regimens to individual needs.
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.
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