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. Unequal height of the shoulders.

This is because scoliosis is a condition characterized by sideways curvature of the spine that can cause asymmetry of the shoulders, shoulder blades, and hips.

A scoliosis screening is a test that checks for this asymmetry by having the child bend forward from the waist and looking for any prominence of the rib cage or the spine.

Choice A is wrong because expansion of the upper intercostal spaces is not a sign of scoliosis, but rather a sign of hyperinflation of the lungs due to conditions such as asthma or emphysema.

Choice B is wrong because increased convex curve of the cervical spine is not a sign of scoliosis, but rather a sign of kyphosis, which is an excessive outward curvature of the upper spine.

Choice C is wrong because increased concave curve of the thoracic spine is not a sign of scoliosis, but rather a sign of lordosis, which is an excessive inward curvature of the lower spine.

A. Deflate the cuff faster when repeating the BP measurement. B. Request a prescription for an antihypertensive medication. C. Use a narrower cuff to repeat the BP measurement. D. Measure the client’s BP in the other arm.

Correct Answer is D

Explanation

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

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?