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.

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.

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.

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Correct Answer is D

Explanation

The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.

It is used for vaginal and colonic examinations and natural childbirth.

Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.

The left arm should be behind the back.

Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.

The lower leg should be straightened and the upper leg should be bent.

Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.

The bed should be flat or slightly tilted.

A. “I will speak with your provider on your behalf.”. B. “I will do my best to fulfill my promises to you.”. C. “I will keep your personal information private.”. D. “I will let you make decisions about your health care.”.

Correct Answer is A

Explanation

The correct answer is choice A: "I will speak with your provider on your behalf."

Choice A rationale: The principle of advocacy in nursing involves supporting and speaking up for clients to ensure their rights, needs, and preferences are respected. By offering to speak with the provider on the client's behalf, the nurse demonstrates advocacy by actively working to represent the client's interests and facilitate communication between the client and the health care team.

Choice B rationale: While promising to fulfill commitments is an aspect of maintaining professional integrity, it does not directly demonstrate advocacy. Advocacy is more about actively supporting the client's rights and needs rather than personal dedication to fulfilling promises.

Choice C rationale: Maintaining the privacy and confidentiality of client information is essential in nursing practice, but it is not specifically related to advocacy. Privacy is a separate ethical principle that focuses on protecting the client's personal information and upholding their right to privacy.

Choice D rationale: Encouraging clients to make decisions about their health care is important for promoting autonomy. However, advocacy involves actively supporting the client's decisions and ensuring their rights are respected, rather than simply allowing them to make decisions.

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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?

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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?