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?
Suctions secretions from the posterior pharynx.
Tests for a gag reflex before performing oral care.
Places the client in a supine position.
Uses an oral airway to keep the teeth apart.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Criminal assault and battery:
Criminal assault and battery involve intentionally causing harm to another person without their consent. In this scenario, the nurse's actions were aimed at providing aid and ensuring the victim's safety. There is no indication of any intentional harm or violence toward the victim.
B. Negligent acts of omission:
Negligent acts of omission occur when a healthcare provider fails to act in a manner consistent with the standard of care, resulting in harm to another person. In this scenario, the nurse took certain actions to assist the victim, such as turning off the engine key and assessing the victim's condition. There is no indication of negligent omission as the nurse took appropriate actions given the circumstances.
C. Abandonment of the victim:
This applies if a healthcare professional leaves a patient in need of care without ensuring appropriate transfer of care. In this scenario, the nurse handed over the situation to EMS before leaving.
D. Good Samaritan immunity:
Good Samaritan laws protect individuals, including nurses, who voluntarily provide assistance in emergency situations from legal liability, as long as their actions are within the scope of their knowledge and training and are performed in good faith. The nurse stopped to help, provided care, and then reported to EMS personnel before leaving, which is consistent with the protection offered by Good Samaritan laws.
Correct Answer is C
Explanation
A. Blood pressure is 142/88 mm Hg:
While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.
B. Radial pulse volume is 3+:
A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.
C. 2+ edema of fingers and hands:
Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.
D. Capillary refill time is 2 seconds:
Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.