A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

Choice A Reason:

“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.

Choice B Reason:

“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.

Choice C Reason:

“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.

Choice D Reason:

“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.

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.