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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: Broccoli is a good source of vitamin K, which is essential for blood clotting. However, it also contains vitamin C, which can interfere with the action of warfarin, a medication used to treat Westerly syndrome. Therefore, broccoli should be consumed in moderation and with caution.
Choice B reason: Bananas are high in potassium, which can affect the heart rhythm and cause arrhythmias in people with Westerly syndrome. Therefore, bananas should be avoided or limited in the diet.
Choice C reason: Mushrooms are low in vitamin K and do not interact with warfarin. They are also a good source of protein, fiber, and antioxidants. Therefore, mushrooms can be safely consumed by people with Westerly syndrome.
Choice D reason: Popcorn is high in sodium, which can increase blood pressure and worsen the symptoms of Westerly syndrome. Therefore, popcorn intake should be limited or avoided.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because suggesting a feeding tube is premature and may alarm the son without knowing the cause of the client's poor appetite.
Choice B reason: This is incorrect because asking why the son thinks the client is not eating may imply that the son is responsible or has the answer, which may make him feel defensive or guilty.
Choice C reason: This is incorrect because dismissing the son's concern as nothing serious may make him feel unheard or invalidated, and may also delay seeking appropriate help for the client.
Choice D reason: This is correct because asking the son to tell more about what happens at mealtime is an open-ended question that shows interest and empathy, and may elicit more information about the client's condition and preferences.
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