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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Tachypnea refers to an increased respiratory rate, which is noted as 29 breaths per minute in this client. Normal respiratory rates typically range from 12 to 20 breaths per minute.
Bradycardia typically refers to a slower than normal heart rate; however, in this context, the client’s heart rate is actually elevated at 104 beats per minute, which is not bradycardic. Thus, this term does not accurately apply to the client’s condition.

A. Increase intestinal peristalsis. B. Prevent esophageal reflux. C. Promote effective swallowing. D. Maintain intact oral mucosa.

Correct Answer is B

Explanation

A. Increasing intestinal peristalsis is not a primary goal related to managing a hiatal hernia. While peristalsis is important for digestion, the focus should be on the esophagus and stomach.
B. Preventing esophageal reflux is the main goal for clients with a hiatal hernia, especially sliding type, as the hernia can cause the stomach to push into the esophagus, leading to reflux symptoms. Strategies to prevent reflux may include dietary modifications and positioning.
C. Promoting effective swallowing may be important in some contexts, but it is not a primary goal associated with managing a hiatal hernia.
D. Maintaining intact oral mucosa is generally a broader nursing goal and not specific to the management of a hiatal hernia. The focus should be on preventing reflux rather than oral mucosa integrity in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits According to the client's vital signs, he is experiencing dropdownanddropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is B

Explanation

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