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
None
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 A
Explanation
Choice A reason: This is correct because a mechanical lift is designed to safely transfer a client who has limited or no mobility and cannot assist with the transfer.
Choice B reason: This is incorrect because the sides of the sling are not for the client to hold onto, but for the nurse to attach the hooks of the lift.
Choice C reason: This is incorrect because the lower end of the sling goes under the client's thighs, not below the client's calves
Choice D reason: This is incorrect because the device does not require the client to use upper body strength, but rather supports the client's weight and movement.
Correct Answer is C
Explanation
Choice A reason: Standing on the client's stronger side may cause the client to lean or fall toward the weaker side. The nurse should stand on the client's weaker side and support the client's trunk and affected arm.
Choice B reason: Raising the bed to waist level may make it harder for the client to move their legs over the edge of the bed. The nurse should lower the bed to the lowest position and raise the head of the bed to a sitting position.
Choice C reason: Flexing hips and knees helps the client use their stronger leg muscles and maintain balance when standing up. The nurse should also place one arm under the client's axilla and the other arm around the client's waist.
Choice D reason: Pivoting on the foot farthest from the bed may cause the client to lose balance and fall. The nurse should pivot on the foot closest to the bed and guide the client to turn and sit on the chair.
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