While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Unpleasant odor of the breath

White patches on the mucosa.

Gumline that has visibly receded.

Discoloration of several teeth.

Answer and Explanation

The Correct Answer is B

Choice A reason: While unpleasant odor can indicate poor oral hygiene or other health issues, it is not as urgent as some other findings.

Choice B reason: White patches on the mucosa can indicate an infection such as oral thrush, which requires medical treatment, making it the most important finding to act upon.

Choice C reason: A receding gumline is a concern for dental health but does not typically require immediate action.

Choice D reason: Discoloration of teeth can indicate various issues, including dietary habits or decay, but is not as immediately concerning as white patches on the mucosa. Bolded text indicates the correct answers and important information.

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Correct Answer is D

Explanation

Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.

Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.

Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.

Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.

A. Hand washing only needs to be performed when exiting the client’s room. B. This client requires contact and droplet precautions. C. A gown and gloves should be worn any time there is potential for contact with secretions. D. A mask should always be worn when in the client’s room. E. This client would require a private room if admitted.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.

Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.

Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.

Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.

Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.

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While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is D

Explanation

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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