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

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.

A. “Why do you think they don’t know what’s happening?” B. “It sounds like you have given up and want to stay mad at your family.”. C. “I think you and I need to talk about your anger with your family.” D. “You are feeling angry that your family continues to wish for a cure?”

Correct Answer is D

Explanation

The correct answer is choice D. “You are feeling angry that your family continues to wish for a cure?”.

This response reflects the client’s feelings and encourages further communication.

It also shows empathy and respect for the client’s situation.

Choice A is wrong because it implies that the client is responsible for their family’s lack of understanding.

It may also make the client feel defensive or guilty.

Choice B is wrong because it is judgmental and dismissive of the client’s feelings.

It may also discourage the client from expressing their emotions.

Choice C is wrong because it focuses on the nurse’s needs rather than the client’s.

It may also sound intrusive or presumptuous to the client.

Hospice care is for people who are in the final stages of an incurable illness and want to focus on comfort and quality of life rather than curative treatments.

Hospice care teams provide physical, emotional, social, and spiritual support to clients and their families.

Hospice care can be provided at home, in a hospital, in a nursing home, or in a specialized hospice center.

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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 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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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?