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.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Enrolling the UAP in a hospital education class on conducting safe client care is not an immediate response and does not address the current situation. It may be a longer-term solution for ongoing education.

Choice B rationale: Praising the UAP for performing oral hygiene and encouraging family participation does not address the immediate safety concern of the procedure being performed correctly.

Choice C rationale: Telling the UAP to continue because the unconscious client is positioned safely is incorrect. The client should not be in a flat side-lying position as it increases the risk of aspiration during oral hygiene.

Choice D rationale: Stopping the procedure and telling the UAP to place the client in a Fowler's position is correct. The Fowler's position helps maintain an open airway and reduces the risk of aspiration during oral hygiene in an unconscious client.

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Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Oﬀering the client a prescribed sleep medication is not the best initial intervention because it may have side eﬀects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caﬀeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caﬀeinated beverages to the client before bedtime.

A. Boiled brown rice, 1/2 cup. B. Canned tomato soup, 1/2 cup. C. Fresh orange slices, 1 small. D. Grilled chicken, 3 ounces. E. Vegetables topped with cheddar cheese.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

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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?

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Naxlex Comprehensive Predictor Exams

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

Correct Answer is B

Explanation

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).

Correct Answer is ["A","C","D"]

Explanation

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