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 C
Explanation
Choice A rationale
Advising the client that it is too late to receive an influenza vaccination once symptoms occur is correct, but it does not address the client’s question about oseltamivir.
Choice B rationale
Explaining that antibiotics are not useful in treating viral infections is correct, but it does not address the client’s question about oseltamivir.
Choice C rationale
Referring the client to the healthcare provider to obtain a medication prescription is the most appropriate response. Oseltamivir is an antiviral medication that can be effective if started within 48 hours of symptom onset.
Choice D rationale
Instructing the client that over-the-counter medications are sufficient to manage influenza symptoms is not appropriate, as oseltamivir can help reduce the severity and duration of the illness if taken early.
Correct Answer is D
Explanation
Choice A rationale
Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.
Choice B rationale
Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.
Choice C rationale
Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.
Choice D rationale
Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.