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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. How many popsicles are available.

This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.

B. If the popsicles are completely frozen.

While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.

C. The color and flavor of gelatin used.

While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.

D. Whether they contain pulp or fruit.

For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.

A. Enter the occurrence after the 1400 notes and identify as "late entry". B. Request removal initiated by the Health Information Manager. C. Create an electronic correction after 1400 notes are officially unlocked. D. Make an electronic addendum following the 1400 documentation.

Correct Answer is A

No explanation

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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