The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

A. Washes hands before handling the needle and syringe:

This action demonstrates an understanding of standard precautions. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions.

B. Wears gloves to dispose of the needle and syringe:

While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.

C. Dons a face mask before administering the medication:

Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.

D. Removes needle before discarding used syringes:

This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture-resistant container.

A. Suctions secretions from the posterior pharynx:

Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.

B. Tests for a gag reflex before performing oral care:

Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.

C. Places the client in a supine position:

Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.

D. Uses an oral airway to keep the teeth apart:

Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.