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 D

Explanation

Choice A reason: Turning on loud music in client care areas is not a good action. Loud music can increase noise levels, disrupt sleep, and cause agitation and anxiety for clients. The nurse should keep the noise level low and provide earplugs or headphones for clients who want to listen to music.

Choice B reason: Assigning different nurses to provide care for clients each day is not a good action. Different nurses may have different styles, routines, and expectations, which can confuse and frustrate clients. The nurse should maintain consistency and continuity of care by assigning the same nurses to the same clients as much as possible.

Choice C reason: While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.

Choice D reason: Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.

A. Measure the intake and output of a client who has received furosemide. B. Reinforce teaching with a client about crutch-gait walking. C. Assess the pain level of a client who has received acetaminophen. D. Check a client's peripheral IV site for redness or swelling.

Correct Answer is A

Explanation

Choice A reason: This is correct because measuring the intake and output of a client is a routine task that can be delegated to an AP.

Choice B reason: This is incorrect because reinforcing teaching with a client requires the nurse's knowledge and judgment and cannot be delegated to an AP.

Choice C reason: This is incorrect because assessing the pain level of a client is a nursing responsibility that involves critical thinking and evaluation and cannot be delegated to an AP.

Choice D reason: This is incorrect because checking a client's peripheral IV site for redness or swelling is a nursing skill that requires the nurse's assessment and intervention and cannot be delegated to an AP.

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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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