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
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.
Correct Answer is C
Explanation
Choice A rationale
Securing tracheostomy ties by making knots close to the tube can cause irritation and pressure on the skin.
Choice B rationale
Removing ties to secure a disposable, soft foam collar with hook and loop fastener is not the most important action when changing the ties of the tracheostomy tube.
Choice C rationale
Leaving the old ties in place until the new ones are secure is the most important action to prevent accidental dislodgement of the tracheostomy tube.
Choice D rationale
Placing knots of the ties laterally to prevent irritation and pressure is important but not the most critical action when changing the ties of the tracheostomy tube.