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 B
Explanation
This type of aphasia is caused by damage to the frontal lobe of the brain, which affects the ability to produce language.
People with expressive aphasia can understand speech and know what they want to say, but they have difficulty saying words or forming sentences.
They may speak in short phrases that require a lot of effort.
Choice A is wrong because receptive aphasia is a type of fluent aphasia that affects the ability to comprehend language.
People with receptive aphasia have difficulty understanding speech and may produce meaningless words or sentences.
Choice C is wrong because global aphasia is the most severe type of aphasia that affects both the production and comprehension of language.
People with global aphasia cannot speak many words and do not understand speech.
They also cannot read or write.
Choice D is wrong because sensory aphasia is not a common term for a type of aphasia.
It may refer to Wernicke’s aphasia, which is another type of fluent aphasia that affects the ability to produce meaningful language.
People with Wernicke’s aphasia can speak fluently but often use incorrect or invented words or phrases.
Correct Answer is A
Explanation
Aspiration is when food or liquid enters the airway and causes choking or infection. Speech therapists can teach clients exercises to strengthen the muscles involved in swallowing, as well as strategies to prevent aspiration, such as changing the position of the head or the texture of the food.
Choice B is wrong because respiratory therapists help clients with breathing problems, not swallowing problems.
They may provide oxygen therapy, chest physiotherapy, or mechanical ventilation.
Choice C is wrong because physical therapists help clients with mobility problems, not swallowing problems.
They may provide exercises, massage, or assistive devices to improve movement and function.
Choice D is wrong because occupational therapists help clients with daily living activities, not swallowing problems.
They may provide training, adaptive equipment, or environmental modifications to enhance independence and quality of life.
Dysphagia is a medical term for swallowing difficulties.
It can be caused by various conditions that affect the nerves or muscles involved in swallowing, such as stroke, head injury, Parkinson’s disease, or esophageal cancer.
Dysphagia can lead to complications such as malnutrition, dehydration, or aspiration pneumonia.
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