Nokea
An adult client is admitted with AIDS and oral candidiasis 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 the UAP?
- A. Assist with personal care, but leave oral care for the nurse to complete.
- B. Provide a soft bristle brush for the client to use during oral care.
- C. Use alcohol-based mouthwash to clean the ulcers.
- D. Apply an antifungal cream to the mouth ulcers.
Correct Answer: B
Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.
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The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?
- A. Experiences an elevation in temperature.
- B. Sleeps on the left side.
- C. Cries vigorously.
- D. Eats.
Correct Answer: C
Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Administer potassium supplements orally.
- B. Increase the client's dietary potassium intake.
- C. Inform the healthcare provider of the need for potassium replacement.
- D. Monitor the client's ECG continuously.
Correct Answer: C
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.
A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the teaching plan?
- A. Avoid taking folic acid supplements
- B. Report any signs of infection immediately
- C. Limit fluid intake to prevent edema
- D. Increase intake of high-calcium foods
Correct Answer: B
Rationale: The correct instruction that the nurse should include in the teaching plan for a client prescribed methotrexate is to report any signs of infection immediately. Methotrexate can suppress the immune system, making the individual more susceptible to infections. Reporting signs of infection promptly allows for timely intervention. Choices A, C, and D are incorrect. Avoiding folic acid supplements is not recommended because methotrexate can lead to folate deficiency, so supplementation may be necessary. There is no direct correlation between fluid intake limitation and methotrexate use. Increasing high-calcium foods is not specifically related to methotrexate therapy for rheumatoid arthritis.
What are early signs of varicella disease?
- A. High fever over 101°F (38.3°C)
- B. General malaise
- C. Increased appetite
- D. Crusty sores
Correct Answer: B
Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?
- A. Irritation of nerve endings
- B. Diminished blood flow
- C. Ischemic tissue changes
- D. Compression of a nerve
Correct Answer: D
Rationale: The correct answer is D: Compression of a nerve. In carpal tunnel syndrome, pain arises from the compression of the median nerve within the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. Choices A, B, and C are incorrect because carpal tunnel syndrome pain is primarily caused by the physical compression of the nerve, rather than irritation of nerve endings, diminished blood flow, or ischemic tissue changes.