A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?

Choice A reason: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The nurse should remove the gloves by grasping the outside of one glove at the wrist and pulling it off inside out, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the other glove at the wrist and pulling it off inside out over the first glove. The nurse should then discard the gloves in a biohazard container.

Choice B reason: Goggles are the second piece of personal protective equipment that the nurse should remove, as they can protect the eyes from splashes or droplets. The nurse should remove the goggles by grasping the earpieces or headband and lifting them away from the face. The nurse should then discard the goggles in a designated receptacle or place them in a designated area for reprocessing.

Choice C reason: Gown is the third piece of personal protective equipment that the nurse should remove, as it can protect the clothing and skin from contamination. The nurse should remove the gown by untying the neck and waist ties and pulling the gown away from the neck and shoulders, touching only the inside of the gown. The nurse should then turn the gown inside out, fold or roll it into a bundle, and discard it in a biohazard container.

Choice D reason: Mask is the last piece of personal protective equipment that the nurse should remove, as it can protect the nose and mouth from inhalation of microorganisms. The nurse should remove the mask by grasping the bottom ties or elastics and then the top ties or elastics and pulling the mask away from the face. The nurse should then discard the mask in a biohazard container.

The correct answer is d. Using two gloved fingers to open the client’s mouth for cleaning. This action is unsafe as it risks injury to both the AP and the client. A padded tongue blade should be used instead.

Choice A reason:

Using an oral care sponge swab moistened with cool water to clean the client’s mouth is appropriate. Oral care sponge swabs are designed to clean the mouth gently and effectively, especially for unconscious patients.

Choice B reason:

Wearing clean gloves to perform mouth care for the client is a standard precaution to prevent infection. Gloves protect both the caregiver and the patient from potential infections.

Choice C reason:

Lowering the side rail on the side of the bed where they will stand to perform mouth care is necessary to safely access the patient. It allows the AP to perform the task without straining or risking injury.

Choice D reason:

Using two gloved fingers to open the client’s mouth for cleaning is unsafe. This method can cause injury to the AP if the patient bites down reflexively. A padded tongue blade should be used to safely open the mouth.