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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Record the amount of blood loss:While important for documentation, patients often cannot accurately estimate blood loss, especially with nasal bleeding. This step is secondary to assessing the client’s current physiological status following multiple episodes.

B. Ask about the last episode of bleeding and how long it took to stop:This can provide useful information for identifying patterns, but it does not assess the client’s immediate condition or potential complications like hypovolemia or hypertension.

C. Check the client's vital signs:Vital signs offer immediate insight into the client’s circulatory and respiratory status. Multiple episodes of epistaxis in one day could indicate hemodynamic instability or uncontrolled hypertension, making this the priority assessment.

D. Inquire if the client had a headache along with the bleeding:A headache could be associated with elevated blood pressure or sinus involvement, but it is not the most urgent concern after repeated nosebleeds. Assessing vital signs takes precedence.

A. drink juices high in vitamin C B. cough into your elbow C. wash hands frequently D. cover the mouth and nose with when sneezing E. use a saline nose spray frequently

Correct Answer is ["B","C","D"]

Explanation

A. Drink juices high in vitamin C: While vitamin C may help support immune function, it does not prevent the transmission of colds to others. This measure is more about personal health and has no direct effect on reducing contagion.

B. Cough into your elbow: Coughing into the elbow instead of the hands prevents the spread of respiratory droplets through touch, reducing the likelihood of contaminating surfaces and infecting others.

C. Wash hands frequently: Hand hygiene is one of the most effective ways to prevent the spread of respiratory viruses. Frequent handwashing helps remove viruses acquired from contaminated surfaces or respiratory secretions.

D. Cover the mouth and nose when sneezing: Covering the mouth and nose with a tissue or elbow during sneezing limits the dispersion of infectious droplets into the air, reducing transmission to others.

E. Use a saline nose spray frequently: Saline sprays may keep nasal passages moist and comfortable, but they do not reduce the risk of spreading infection to others. Their use is symptomatic, not preventive from a contagion standpoint.

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A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 55-year-old man presents to the health nurse at his workplace with epistaxis. He reports he has had four nosebleeds today, and he is concerned because he can usually control the bleeding himself. What would be the most helpful assessment after the nurse has stopped the bleeding?

Correct Answer is C

Explanation

The nurse advises that, to reduce the risk of giving a cold to another, one should: (Select 3 correct answers)

Correct Answer is ["B","C","D"]

Explanation

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