A nurse is assessing a client's blood pressure. The reading is 140/90 mmHg. What does the systolic pressure indicate?

A. White, cheesy, curd-like patches on the buccal mucosa are characteristic of oral candidiasis (thrush), a common fungal infection of the mouth caused by Candida albicans. These patches can often be wiped off, leaving a red, raw, or bleeding surface underneath. This is the classic presentation, making this the correct answer.

B. Small, painful round ulcers on the oral mucosa describe aphthous ulcers (canker sores), which are not fungal infections. They are usually idiopathic or associated with stress, trauma, or immune factors, so this option is incorrect.

C. Clear vesicles with a red base that evolve into pustules are more consistent with herpetic lesions caused by the herpes simplex virus. They are viral, not fungal, in origin, making this incorrect.

D. Chalky white, thick raised patches on the tongue may suggest leukoplakia, which is a precancerous lesion often linked to smoking or chronic irritation. Leukoplakia is not caused by fungal infection, so this option is incorrect.

A. There is no evidence of inappropriate behavior by the UAP. The UAP accurately reported the vital signs. There is no indication of misconduct or negligence that would require reporting to a manager.

B. Although one value is abnormal, the nurse should not delegate reassessment of an abnormal finding back to the UAP. When abnormal data are reported, the registered nurse is responsible for validating and further assessing the finding personally. Re-delegating does not meet the RN’s accountability for clinical judgment.

C. A pulse oximetry reading of 91% on room air is below normal (normal is 95–100%), indicating mild hypoxemia. However, before initiating an intervention such as oxygen therapy, the nurse must first validate the abnormal finding. Pulse oximetry readings can be affected by poor probe placement, cold extremities, nail polish, motion, or equipment error. Immediate oxygen administration without reassessment is premature.

D. A pulse oximetry of 91% is abnormal and requires follow-up. The nurse’s first action should be to personally reassess the oxygen saturation to validate the accuracy of the reading. This includes checking probe placement, ensuring proper perfusion, and assessing the client’s respiratory status. Once validated, appropriate interventions such as oxygen therapy can be initiated if necessary.