A nurse is collecting data from a client who is receiving IV fluid replacement to treat diarrhea but now has oliguria. Laboratory results include a potassium level of 5.6 mEq/L. The nurse should report which of the following findings to the provider immediately?

Choice A Reason:
"He may need a feeding tube" is inappropriate response. Suggesting a feeding tube without further assessment or information might be premature and could cause unnecessary concern or anxiety for the son. It's essential to explore the situation more before proposing such an intervention.

Choice B Reason:
"Tell me more about what happens at mealtime” is appropriate response. This response encourages the son to provide further details about the situation, allowing the nurse to gather more information about the specific issues or challenges related to the client's eating habits. Understanding the circumstances around mealtime can help the nurse identify potential reasons for the lack of appetite or eating difficulties and offer more targeted guidance or solutions.

Choice C Reason:
"Why do you think he's not eating?" This response is inappropriate. While asking about the son's thoughts is valuable, this question might not directly address the situation at hand or provide immediate assistance or guidance to address the client's eating difficulties.

Choice D Reason:
"I'm sure it's nothing serious and his appetite will return soon” is inappropriate response. Offering reassurance without understanding the underlying cause may downplay a potentially concerning issue. It's crucial to investigate the reasons behind the lack of appetite before assuming it will resolve without further action.

Choice A Reason:

Lowering the side rail on the side of the bed where the AP will stand to perform mouth care is a safety measure. It provides better access to the client and allows the AP to perform the task more comfortably and effectively. This action helps prevent the AP from leaning over an elevated side rail, reducing the risk of injury to themselves or the client.

Choice B Reason:

Wearing clean gloves to perform mouth care for the client is a safety measure. Wearing gloves is crucial to maintain hygiene and prevent the transmission of microorganisms during mouth care.

Choice C Reason:

Using an oral care sponge swab moistened with cool water to clean the client's mouth is a safety measure. Using a moistened oral care sponge swab is a suitable method for providing mouth care to an unconscious client, helping to keep the mouth clean and moist.

Choice D Reason:

Using two gloved fingers to open the client's mouth for cleaning is NOT a safety measure. In this situation, using fingers to open the client's mouth poses a risk of injury or discomfort to the client. It's important to handle an unconscious patient's mouth with care and avoid using fingers to open the mouth forcibly.