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 B

Explanation

A. "I am sorry to disturb you at a difficult time. This can wait until later."

This response acknowledges the client's distress but does not actively engage with the client's emotions or offer support. It also suggests postponing the assessment, which may not be necessary if the client is willing to discuss their feelings.

B. “While touching the client's forearm, asks, 'Would you like to talk about it?'"

This response demonstrates empathy and offers the client an opportunity to express their feelings if they wish to do so. By gently touching the client's forearm and asking if they would like to talk, the nurse conveys support and openness to the client's emotional needs.

C. "This is a bad time. I can see you are upset. I can come back later."

While this response acknowledges the client's emotions and offers to return later, it may not be the most helpful approach. It assumes that the client does not want to engage in conversation at that moment without giving them the opportunity to express their preferences.

D. “Gives the client a hug and says, 'It is okay to cry when you are sad.'"

While offering physical comfort like a hug can be appropriate in some situations, it's important to respect the client's personal boundaries and preferences, especially if they are in distress. Additionally, some clients may not feel comfortable with physical touch from healthcare providers. This response also assumes the client's emotions without directly addressing their needs or offering them an opportunity to express themselves verbally.

A. Administer PRN oral pain medication. B. Review the pain medications prescribed. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is C

Explanation

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

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