A nurse observes 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?
Lowering the side rail on the side of the bed where they will stand to perform mouth care.
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.
Using two gloved fingers to open the client’s mouth for cleaning.
The Correct Answer is D
The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.
Choice A rationale:
Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.
Choice B rationale:
Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.
Choice C rationale:
Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.
Choice D rationale:
Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.
This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.
The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.
Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.
Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.
It has no effect on the oxygen saturation level.
Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.
A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.
Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.
The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.
Correct Answer is ["7"]
Explanation
Determine the total daily dose required in milligrams:
The prescribed dose is 80 mg/kg/day.
The child's weight is 35 kg.
Totaldailydose=80mg/kg/day×35kg
Calculate the total daily dose:
Totaldailydose=2800mg/day
Divide the total daily dose into four doses:
Doseperadministration: 2800mg/day ÷ 4 =700mg
Determine the volume of the oral suspension to administer per dose:
The available concentration of sucralfate oral suspension is 1 g/10 mL.
Convert 1 g to mg:
1g=1000mg.
Calculate the volume needed for 700 mg:
Volume(mL) = Desireddose(mg)÷Concentration(mg/mL)
Concentration = 1000mg÷10mL = 100mg/mL
Volume(mL) = 700 mg ÷ 100mg/mL
= 7 mL
Therefore, the nurse should administer 7 mL of sucralfate oral suspension per dose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.