The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?
Enroll the UAP in a hospital education class on conducting safe client care.
Praise the UAP for doing the oral hygiene but encourage family participation.
Tell the UAP to continue because the unconscious client is positioned safely.
Stop the procedure and tell the UAP to place the client in a Fowler's position.
None
None
The Correct Answer is C
Choice A rationale: Enrollment in a remedial education class is unnecessary because the UAP is currently demonstrating the correct, evidence-based technique for providing oral care to an unconscious client to prevent aspiration.
Choice B rationale: While positive reinforcement is beneficial, the primary focus should be on the clinical safety of the procedure. Encouraging family participation is secondary to ensuring the UAP maintains proper safety protocols.
Choice C rationale: The side-lying position, combined with a towel and basin under the chin, allows secretions to drain out of the mouth by gravity. This is the safest position to prevent aspiration.
Choice D rationale: Placing an unconscious client in Fowler's position increases the risk of the tongue falling back and secretions being aspirated into the lungs. The flat, side-lying position is much safer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A:
The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:
The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.
Choice B rationale:
This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.
Choice C rationale:
This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.
Choice D rationale:
This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.
Correct Answer is B
Explanation
This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non-pharmacological method of pain relief that can enhance the effect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood flow.
A. Dimming the lights in the room and closing the door may not be enough to help the client deal with his pain and may not address his psychological or emotional needs.
C. Turning the television on to the client's favorite show may not be effective in helping the client deal with his pain and may be distracting or irritating for him.
D. Obtaining a prescription for a higher dose of pain medication may not be necessary or appropriate for this client and may increase the risk of side effects or dependence. The PN should assess the client's pain level and response to the current dose before requesting a change in medication.
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