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 C

Explanation

The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.

Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.

There is no legal requirement for this.

Choice B is wrong because a licensed health care worker does not have to perform postmortem care.

The family can perform the care themselves if they wish, with or without the assistance of a health care worker.

Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.

Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.

A. Autonomy B. Fidelity. C. Veracity. D. Beneficence.

Correct Answer is D

Explanation

Beneficence is the ethical principle of doing good and acting in the best interest of the patient. By administering pain medication prior to turning the client, the nurse is reducing the client’s suffering and promoting their well-being.

Choice A. Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to self-determination and decision-making. The nurse is not asking for the client’s consent or preference before giving pain medication or turning them.

Choice B. Fidelity is wrong because fidelity is the ethical principle of being faithful and loyal to the patient and honoring one’s commitments and promises. The nurse is not demonstrating fidelity by giving pain medication or turning the client.

Choice C. Veracity is wrong because veracity is the ethical principle of telling the truth and being honest with the patient. The nurse is not providing any information or education to the client before giving pain medication or turning them.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?