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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Showing the client a video demonstration of peak flow meter use is a helpful teaching strategy, but it is not the first action that the nurse should take. The nurse should first assess the client's baseline knowledge and readiness to learn before providing any information or instruction.
Choice B reason: Observing the client using the peak flow meter is a way to evaluate the client's learning and skill, but it is not the first action that the nurse should take. The nurse should first determine the client's knowledge of the use of the peak flow meter and then teach the client how to use it correctly.
Choice C reason: Emphasizing the importance of the daily use of the peak flow meter is a way to motivate the client to adhere to the treatment plan, but it is not the first action that the nurse should take. The nurse should first assess the client's knowledge of the use of the peak flow meter and then explain the benefits and rationale of using it regularly.
Choice D reason: Determining the client's knowledge of the use of the peak flow meter is the first action that the nurse should take, as it follows the principle of the nursing process. The nurse should start with assessment, then proceed with planning, implementation, and evaluation. By assessing the client's knowledge, the nurse can identify the client's learning needs, gaps, and preferences, and tailor the teaching accordingly.
Correct Answer is C
Explanation
Choice A reason: Talking at a rapid rate is not a good action to promote communication with a client who has hearing loss. Talking too fast can make it harder for the client to follow the conversation, lip-read, or use hearing aids. The nurse should talk at a normal rate and pause between sentences.
Choice B reason: Using short phrases is not a good action to promote communication with a client who has hearing loss. Using short phrases can make the message unclear, incomplete, or condescending. The nurse should use complete sentences and avoid jargon, slang, or abbreviations.
Choice C reason: Decreasing background noise is a good action to promote communication with a client who has hearing loss. Background noise can interfere with the client's ability to hear and understand the nurse. The nurse should reduce or eliminate any sources of noise, such as TV, radio, or other people, and choose a quiet and well-lit place to talk.
Choice D reason: Speaking in a loud voice is not a good action to promote communication with a client who has hearing loss. Speaking too loud can distort the sound, cause discomfort, or offend the client. The nurse should speak in a clear and natural voice and adjust the volume according to the client's feedback.
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