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

Explanation

A. Administer a prescribed opioid analgesic: Pain relief is the priority in this situation, as the client is experiencing severe pain from the renal calculi.
B. Strain the urine for the presence of stones: Straining urine is important but not the first intervention when the client is in severe pain.
C. Prepare the client for a prescribed computed tomography (CT) scan: Although imaging is needed, pain relief should be prioritized first.
D. Obtain a urine specimen for analysis: While urine analysis is necessary, pain management should take precedence.

A. Evaluate the UAP for signs of improvement. B. Plan for scheduled break times. C. Note date and time of the behavior. D. Discuss the issue privately with the UAP.

Correct Answer is C,D,B,A

Explanation

First, the manager should document the behavior to create an official record of what occurred. Next, it is important to address the issue directly with the UAP in a private discussion, giving the individual an opportunity to explain their actions. Following the discussion, planning for scheduled breaks is a proactive measure to ensure that the UAP has structured downtime, reducing the likelihood of similar behavior. Finally, evaluating the UAP for signs of improvement will help determine whether the intervention strategies have been effective and whether further action is necessary.

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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 renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is C,D,B,A

Explanation

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.

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An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

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The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?