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 means low sodium levels in the blood.
Sodium is an electrolyte that helps regulate fluid balance and nerve and muscle function.
Vomiting and diarrhea can cause dehydration and loss of sodium through fluids.
Normal sodium levels are between 135 to 145 millimole/Liter.
Choice A is wrong because hypermagnesemia means high magnesium levels in the blood.
Magnesium is another electrolyte that helps with nerve and muscle function, as well as blood pressure and blood sugar regulation.
Hypermagnesemia is rare and usually caused by kidney failure or excessive use of magnesium supplements or laxatives.
Normal magnesium levels are between 1.46 to 2.68 milligram/deciliter.
Choice C is wrong because hypocalcemia means low calcium levels in the blood.
Calcium is an electrolyte that helps with bone health, muscle contraction, blood clotting and nerve signaling.
Hypocalcemia can be caused by vitamin D deficiency, kidney disease, thyroid problems or certain medications.
Normal calcium levels are between 8.8 to 10.7 milligram/deciliter.
Choice D is wrong because hyperkalemia means high potassium levels in the blood.
Potassium is an electrolyte that helps with nerve and muscle function, especially the heart.
Hyperkalemia can be caused by kidney disease, diabetes, adrenal gland disorders or certain medications.
Normal potassium levels are between 3.6 to 5.5 millimole/Liter.
Correct Answer is D
Explanation
The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.
The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.
The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.
Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.
Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.
Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.
Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).
Higher pressures may damage the wound tissue and increase the risk of infection.
Lower pressures may not be effective in removing debris and bacteria from the wound.
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