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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?

A.

Offer the client mouthwash for thorough cleansing after brushing teeth.

B.

Assist with personal care, but leave oral care for the nurse to complete.

C.

Provide a soft-bristled toothbrush for the client to use during oral care.

D.

Wear sterile gloves when cleansing any areas of infected mucosa.

Answer and Explanation

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 C

Explanation

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.

Correct Answer is B

Explanation

Choice A rationale

Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.

Choice B rationale

Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.

Choice C rationale

C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.

Choice D rationale

Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.

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