A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
Start the client on a broad-spectrum antibiotic.
Encourage the client to rinse their mouth after administering fluticasone.
Document the finding as a known side effect.
Obtain an oral specimen for culture & sensitivity.
The Correct Answer is B
A. Start the client on a broad-spectrum antibiotic: Oral lesions from fluticasone are often fungal (e.g., oral candidiasis), not bacterial. Starting antibiotics without identifying the causative agent can worsen fungal infections and is not a first-line or appropriate action.
B. Encourage the client to rinse their mouth after administering fluticasone: Fluticasone, an inhaled corticosteroid, can cause oral thrush if residue remains in the mouth. Rinsing the mouth after each use helps remove residual medication and prevent fungal overgrowth.
C. Document the finding as a known side effect: While oral lesions are a known side effect, documentation alone does not address the issue or help prevent recurrence. Intervention to reduce further irritation or infection is necessary along with documentation.
D. Obtain an oral specimen for culture & sensitivity: A culture may be indicated if the lesions are persistent, worsening, or unresponsive to initial interventions. For early or mild lesions suggestive of candidiasis, encouraging mouth rinsing is the more immediate step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Antihistamine:Antihistamines are the first-line treatment for allergic reactions such as itchy, watery eyes, sneezing, and coughing caused by allergens like grass pollen. They block histamine, the chemical responsible for allergic symptoms, providing effective relief in seasonal allergies.
B. Antitussive:Antitussives suppress coughing and are used for dry, nonproductive coughs. They do not address the underlying allergic reaction or associated symptoms like sneezing and itchy eyes, making them inappropriate for this case.
C. Decongestant:Decongestants relieve nasal congestion by constricting blood vessels in the nasal mucosa. While they may help with stuffiness, they do not treat the histamine-mediated symptoms such as watery eyes or sneezing effectively.
D. Expectorant:Expectorants thin mucus to help with productive coughs. They are not helpful in treating allergic reactions and will not relieve the patient's symptoms caused by grass allergy exposure.
Correct Answer is A
Explanation
A. Use an N95 respirator when entering the room:An N95 respirator provides a tight seal and filters airborne particles, which is essential for preventing transmission of Mycobacterium tuberculosis. Because TB spreads through airborne droplets, wearing an N95 mask is the most important protection for healthcare workers.
B. Place the patient in a room with positive room airflow:Positive pressure airflow pushes air out of the room, which risks contaminating surrounding areas. TB patients must be placed in negative pressure rooms to contain and filter airborne pathogens safely within the room.
C. Open the windows in the room for extra ventilation:While increasing ventilation may reduce airborne concentration of pathogens in certain settings, it is not a recommended infection control method in clinical environments.
D. Use a surgical mask when entering the room:Surgical masks do not effectively filter small airborne particles like TB bacilli. They are intended for droplet precautions, not airborne precautions, and therefore offer inadequate protection for staff entering a TB patient's room.
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