A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Using an oral care sponge swab moistened with cool water to clean the client's mouth.

Wearing clean gloves to perform mouth care for the client.

Lowering the side rail on the side of the bed where they will stand to perform mouth care.

Using two gloved fingers to open the client's mouth for cleaning.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is B

Explanation

Choice A reason: Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.

Choice B reason: Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.

Choice C reason: Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.

Choice D reason: Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.

A. I can eat broccoli as a snack. B. I should avoid bananas in my diet. C. I can have mushrooms on my pizza. D. I need to limit popcorn intake.

Correct Answer is B

Explanation

Choice A reason: Broccoli is a good source of vitamin K, which is essential for blood clotting. However, it also contains vitamin C, which can interfere with the action of warfarin, a medication used to treat Westerly syndrome. Therefore, broccoli should be consumed in moderation and with caution.

Choice B reason: Bananas are high in potassium, which can affect the heart rhythm and cause arrhythmias in people with Westerly syndrome. Therefore, bananas should be avoided or limited in the diet.

Choice C reason: Mushrooms are low in vitamin K and do not interact with warfarin. They are also a good source of protein, fiber, and antioxidants. Therefore, mushrooms can be safely consumed by people with Westerly syndrome.

Choice D reason: Popcorn is high in sodium, which can increase blood pressure and worsen the symptoms of Westerly syndrome. Therefore, popcorn intake should be limited or avoided.

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A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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