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 B

Explanation

Choice A reason: Isopropyl alcohol is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Isopropyl alcohol is effective against some bacteria, viruses, and fungi, but not against Clostridium difficile spores. These spores are resistant to alcohol and can survive on surfaces for a long time.

Choice B reason: Chlorine bleach is a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Chlorine bleach is effective against a wide range of microorganisms, including Clostridium difficile spores. It can kill the spores and prevent their spread. The nurse should use a diluted bleach solution (1:10) and follow the manufacturer's instructions for contact time and safety precautions.

Choice C reason: Chlorhexidine is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Chlorhexidine is an antiseptic that is used for skin cleansing and wound care. It is not effective against Clostridium difficile spores and can promote their growth.

Choice D reason: Triclosan is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Triclosan is an antibacterial agent that is used in some soaps, toothpastes, and cosmetics. It is not effective against Clostridium difficile spores and can contribute to antibiotic resistance.

Correct Answer is ["7"]

No explanation

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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 disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use?

Correct Answer is B

Explanation

Correct Answer is ["7"]

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