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.

None

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 D

Explanation

Choice A reason: Increased convex curve of the cervical spine is not an indication of scoliosis, but of kyphosis. Kyphosis is a condition that causes a forward rounding of the upper back, resulting in a hunched posture.

Choice B reason: Increased concave curve of the thoracic spine is not an indication of scoliosis, but of lordosis. Lordosis is a condition that causes an excessive inward curvature of the lower back, resulting in a swayback posture.

Choice C reason: Expansion of the upper intercostal spaces is not an indication of scoliosis, but of emphysema. Emphysema is a lung disease that causes the air sacs to become damaged and enlarged, resulting in difficulty breathing and a barrel chest.

Choice D reason: Unequal height of the shoulders is an indication of scoliosis. Scoliosis is a condition that causes a sideways curvature of the spine, resulting in an asymmetrical appearance of the shoulders, hips, and waist.

A. 1 small banana B. 1 medium fresh green pear C. 1 small pink grapefruit D. 1 small apple with the skin

Correct Answer is C

Explanation

Choice A reason: A small banana contains about 8.7 mg of vitamin C, which is only 10% of the recommended daily intake for adults.

Choice B reason: A medium fresh green pear contains about 4.3 mg of vitamin C, which is only 5% of the recommended daily intake for adults.

Choice C reason: A small pink grapefruit contains about 38.4 mg of vitamin C, which is 43% of the recommended daily intake for adults. This is the highest amount of vitamin C among the four choices.

Choice D reason: A small apple with the skin contains about 8.4 mg of vitamin C, which is only 9% of the recommended daily intake for adults.

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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

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