An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates to the assistive personnel (AP) and discusses how to assist the client. Which instruction should the nurse provide?
Offer the client mouthwash for thorough cleansing after brushing teeth.
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.
Wear sterile gloves when cleansing any areas of infected mucosa.
The Correct Answer is C
Choice A rationale
Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.
Choice B rationale
While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.
Choice C rationale
Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.
Choice D rationale
Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.
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Correct Answer is A
Explanation
Choice A rationale
Irregular rapid heart rate (tachycardia) is a serious side effect of albuterol and warrants immediate intervention. Albuterol is a beta-2 agonist that can cause stimulation of beta-1 receptors in the heart, leading to tachycardia and potential arrhythmias.
Choice B rationale
Uncontrollable shaking (tremors) is a common side effect of albuterol due to its stimulation of beta-2 receptors in skeletal muscles. While uncomfortable, it is not typically life-threatening.
Choice C rationale
Increased anxiety can occur with albuterol use due to its stimulant effects on the central nervous system. However, it is not as immediately dangerous as tachycardia.
Choice D rationale
Throat irritation is a minor side effect of albuterol and does not require immediate intervention.
Correct Answer is A
Explanation
Choice A rationale
Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.
Choice B rationale
Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.
Choice C rationale
Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.
Choice D rationale
Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.