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 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.

A. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). B. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with the patient. C. Report the COVID-19 result to the local health department according to Centers for Disease Control and Prevention (CDC) guidelines. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is A

Explanation

A. Isolating the client is the most critical action to prevent the potential spread of COVID-19 to others, especially since the client is exhibiting symptoms consistent with the virus.
B. While counseling family members is important, it is secondary to ensuring the immediate safety of others in the healthcare setting.
C. Reporting results is necessary for public health tracking but does not take precedence over immediate isolation measures.
D. Teaching the client preventive measures is important, but again, it should follow ensuring isolation to mitigate any risk of exposure to others.

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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

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