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 C

Explanation

Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.

Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.

Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.

Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.

A. Calf swelling B. Clammy skin C. Tortuous veins D. Bradycardia

Correct Answer is A

Explanation

Choice A reason: Calf swelling is a sign of deep vein thrombosis, which is a blood clot that forms in a deep vein, usually in the lower leg or thigh. The clot can block the blood flow and cause inflammation, pain, and edema. The nurse should measure the circumference of both calves and compare them for any difference. The nurse should also report any other signs of deep vein thrombosis, such as warmth, redness, or tenderness.

Choice B reason: Clammy skin is not a sign of deep vein thrombosis, but of shock. Shock is a life-threatening condition that occurs when the body's organs do not receive enough blood and oxygen. The nurse should monitor the client's vital signs, such as blood pressure, pulse, and temperature, and report any abnormal findings.

Choice C reason: Tortuous veins are not a sign of deep vein thrombosis, but of varicose veins. Varicose veins are enlarged and twisted veins that appear near the surface of the skin, usually in the legs. They are caused by weak or damaged valves that allow blood to pool and stretch the veins. The nurse should assess the client's skin for any ulcers, bleeding, or infection.

Choice D reason: Bradycardia is not a sign of deep vein thrombosis, but of a slow heart rate. Bradycardia is a condition that occurs when the heart beats less than 60 times per minute. It can be caused by various factors, such as medication, heart disease, or hypothyroidism. The nurse should check the client's pulse and rhythm, and report any irregularities.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is immobile and has a potential deep vein thrombosis. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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