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 D

Explanation

A. Feelings of disorientation may be a symptom of heroin use, but addressing the client’s mental health, particularly suicidal tendencies, takes precedence.
B. Undiagnosed social anxiety symptoms may be important for long-term care, but the immediate concern is the risk of self-harm or overdose.
C. Family history of schizophrenia is relevant for mental health but does not take priority over assessing suicide risk in a client using heroin.
D. A history of suicide attempts is crucial for the nurse to consider because individuals using heroin may be at an increased risk of self-harm due to the psychological effects of substance use and potential for overdose. Immediate safety and suicide risk assessment are critical.

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

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is D

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

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