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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Digoxin is a medication used to treat various heart conditions, such as abnormal heart rhythms and heart failure.It works by improving the strength and efficiency of the heart, or by controlling the rate and rhythm of the heartbeat.
One of the important things to monitor when giving digoxin to an infant is the pulse rate. Digoxin can lower the heart rate, which can be dangerous if it becomes too slow.Therefore, the pulse rate should be checked for one full minute before administering digoxin, and the medication should be held if the pulse rate is below 90 beats per minute (bpm) for an infant.
In this case, the infant’s heart rate is 120 bpm, which is within the normal range for a 2-month-old. Therefore, the correct action for the PN to take is to administer the medication and document the heart rate. This is optionbin the list of choices. Optionais incorrect because there is no need to hold the medication or recheck the heart rate in one hour. Optioncis incorrect because there is no need to alert the charge nurse unless there is a problem with the infant’s condition or the medication. Optiondis incorrect because holding the medication and documenting cardiac assessment is not appropriate for a normal heart rate.
Correct Answer is ["40"]
Explanation
The client’s 0730 finger stick glucose is 271 mg/dL. According to the sliding scale parameters, the client should receive:
Step 1: Determine the amount of insulin aspart based on the sliding scale. Since the glucose level is 271 mg/dL, which falls in the range of 270 to 300 mg/dL, the client should receive 15 units of insulin aspart.
Step 2: Add the amount of NPH insulin to the amount of insulin aspart. The client has a prescription for NPH insulin 25 units before breakfast. So, the total amount of insulin this client should receive is 25 units (NPH insulin) + 15 units (insulin aspart) = 40 units.
So, the total amount of insulin this client should receive is40 units.
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