An adult client 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 client. Which instruction should the nurse provide to the UAP?
Assist with personal care, but leave oral care for the nurse to complete.
Provide a soft-bristled toothbrush for the client to use during oral care.
Offer the client mouthwash for thorough cleansing after brushing teeth.
Wear sterile gloves when cleansing any areas of infected mucosa.
The Correct Answer is B
A. While the nurse can perform oral care, it is essential for the UAP to assist where appropriate, and oral care should not be solely left for the nurse.
B. A soft-bristled toothbrush is the best option for the client with painful mouth ulcers, as it is gentle and reduces the risk of further irritation.
C. Offering mouthwash may not be appropriate, especially if it contains alcohol, as it could further irritate the ulcers; additionally, thorough cleansing is typically more effective with careful brushing rather than rinsing alone.
D. Wearing sterile gloves is unnecessary for oral care; standard precautions, including clean gloves, should be used, but sterile gloves are not required for this type of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperventilation leads to respiratory alkalosis, not acidosis, as it reduces carbon dioxide levels in the blood.
B. Respiratory acidosis is characterized by the accumulation of carbon dioxide in the blood, leading to a decrease in blood pH. This is the fundamental process underlying respiratory acidosis.
C. While the kidneys can help eliminate carbon dioxide through bicarbonate production, respiratory acidosis primarily results from respiratory failure rather than renal conversion.
D. Elevated blood oxygen levels do not stimulate the respiratory rate; rather, low oxygen levels typically prompt an increased respiratory effort.
Correct Answer is []
Explanation
Condition: The combination of severe abdominal pain, elevated inflammatory markers, and risk factors, along with the need for urgent care and surgical evaluation, suggests that GERD may be a significant underlying issue, especially in the context of potential complications.
Actions to Take
- Prepare for surgery: Given the client's presentation of severe abdominal pain, elevated white blood cell count, and possible abdominal rigidity, surgical intervention may be necessary to rule out conditions like acute cholecystitis or perforation.
- Transfer to high-risk level of care: Due to the client's elevated vital signs, including tachycardia and fever, along with the severe pain radiating to the shoulder, close monitoring in a high-risk area is warranted.
Parameters to Monitor
- Pain: Regular assessment of the client's pain level is crucial to evaluate the effectiveness of interventions and to monitor any changes in the severity of the pain.
- Signs and symptoms of abdominal perforation: Monitoring for indications such as increased abdominal tenderness, rigidity, fever, and changes in vital signs is essential to detect any complications promptly.
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