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
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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Related Questions
Correct Answer is C
Explanation
A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy.
B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise.
C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation.
D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.
Correct Answer is ["3.3"]
Explanation
Step 1: Convert the client’s weight from pounds to kilograms
22lb÷2.2=10kg
Step 2: Calculate the total daily dose
50mg/kg/day×10kg=500mg/day
Step 3: Divide the total daily dose into 3 doses (every 8 hours)
500÷3≈166.7mgperdose
Step 4: Use the concentration of the suspension to determine how many mL to give
The label says:
250 mg per 5 mL
250mg/5mL=166.7mg/ xmL
Solve for x:
x=166.7×5/250
=833.5/250=3.33mL
Final Answer: 3.3 mL per dose (rounded to the nearest tenth)
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