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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A: Dysrhythmia
There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.
Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.
While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.
Rationale for Choice B: Toxicity
There is no information in the question stem to suggest that the patient is experiencing toxicity.
Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.
While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.
Rationale for Choice C: Anemia
There is no information in the question stem to suggest that the patient is anemic.
Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.
While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.
Rationale for Choice D: Pneumonia
The patient is a 51-year-old male with a diagnosis of pneumonia.
Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.
The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.
Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.
Therefore, pneumonia is the most likely condition that the patient has based on the information provided.
Correct Answer is B
Explanation
Choice A rationale:
While ABGs can provide valuable information about a patient's respiratory status, they are not routinely required prior to postural drainage in patients with COPD.
ABGs might be considered if the patient is experiencing acute respiratory distress or if there are concerns about their oxygenation or ventilation status.
However, in the absence of such concerns, obtaining ABGs would not be necessary and could potentially cause discomfort or anxiety for the patient.
Choice C rationale:
Performing postural drainage immediately after meals is not recommended for patients with COPD.
This is because eating can cause a feeling of fullness in the stomach, which can make it difficult for the patient to breathe deeply and effectively during the procedure.
Additionally, there is a risk of aspiration if the patient were to vomit during or after postural drainage.
It is generally recommended to perform postural drainage at least 1-2 hours after meals to reduce these risks.
Choice D rationale:
Instructing the patient to breathe shallow and fast is not appropriate for postural drainage.
The goal of postural drainage is to help the patient mobilize and expectorate secretions from the lungs.
This is best achieved by encouraging the patient to breathe deeply and slowly, which helps to open up the airways and promote mucus clearance.
Shallow, rapid breathing can actually make it more difficult to clear secretions and can lead to increased shortness of breath.
Choice B rationale:
Explaining that the patient may be placed in five positions is the most appropriate approach for postural drainage in a patient with COPD.
This is because different positions help to drain different areas of the lungs. The five positions typically used for postural drainage are:
Head down position (to drain the lower lobes)
Prone position (to drain the posterior segments of the lungs)
Right lateral position (to drain the right middle lobe and right lower lobe) Left lateral position (to drain the left lower lobe)
Sitting upright position (to drain the upper lobes)
By placing the patient in these different positions, the nurse can help to ensure that all areas of the lungs are drained effectively.
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