The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction(s) should the nurse provide the UAP? Select all that apply.

Remove the gloved finger from the mouth.

Flex the client's neck forward.

Apply lubricant to the tootherte

Turn the client's head to the side.

Elevate the head of the bed to semi-Fowler's

Answer and Explanation

Correct Answer : B,D,E

A. Removing the gloved finger from the mouth is not necessarily appropriate unless the UAP is at risk of injury or if the client has a gag reflex that is causing a problem.

B. Flex the client's neck forward helps facilitate drainage and reduces the risk of aspiration while providing oral care.

C. Applying lubricant to the toothettes is not a priority in this scenario and may not be necessary.

D. Turn the client's head to the side is an important safety measure to prevent aspiration of saliva or oral care products.

E. Elevate the head of the bed to semi-Fowler's helps reduce the risk of aspiration by allowing gravity to assist in the drainage of fluids and secretions.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Bradykinesia (slowness of movement) is a hallmark symptom of Parkinson's disease and will directly affect the client's mobility, requiring intervention to assist with movement and prevent falls.

B. Stooped posture is common in Parkinson's disease and can contribute to impaired balance and increase the risk of falls, making interventions for posture and mobility necessary.

C. Orthostatic hypotension is not specifically a mobility issue, but it can affect the client's overall safety and risk for falls. It may require monitoring and interventions to address blood pressure changes, but it is not as directly related to mobility as the other symptoms.

D. Shuffling, propulsive gait is a typical motor symptom of Parkinson's disease and increases the risk of falls, necessitating planning for interventions to improve gait and balance.

E. Muscular rigidity is another classic symptom that can limit the client's mobility, causing difficulty with movement, and requires interventions to improve range of motion and reduce stiffness.

A. Determine the diameter and depth of a client's dermal ulcer. B. Evaluate a client's mobility progress toward the plan of care. C. Titrate oxygen to the prescribed parameters. D. Procure platelet products from the blood bank.

Correct Answer is D

Explanation

A. Determining the diameter and depth of a dermal ulcer requires clinical assessment and should be done by a nurse (RN or PN).

B. Evaluating a client's mobility progress requires clinical judgment to assess the effectiveness of interventions, which is the responsibility of a nurse.

C. Titrating oxygen involves adjusting the oxygen flow based on clinical criteria, which is a nursing responsibility requiring assessment skills and judgment.

D. Procure platelet products from the blood bank is within the scope of practice for UAPs, as it involves logistical tasks that do not require clinical judgment or assessment.

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The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction(s) should the nurse provide the UAP? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is D

Explanation

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