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 C
The correct answer is choice c. Tell the UAP to continue because the unconscious client is positioned safely.
Choice A rationale:
Enrolling the UAP in a hospital education class on conducting safe client care is a proactive measure, but it is not an immediate action required in this scenario. The UAP is already performing the task correctly.
Choice B rationale:
Praising the UAP for doing the oral hygiene and encouraging family participation is positive reinforcement, but it does not address the immediate task at hand. The focus should be on ensuring the client’s safety during the procedure.
Choice C rationale:
Telling the UAP to continue because the unconscious client is positioned safely is the correct action. The side-lying position with an emesis basin under the chin is appropriate for an unconscious client as it helps prevent aspiration by allowing secretions to drain out of the mouth.
Choice D rationale:
Stopping the procedure and telling the UAP to place the client in a Fowler’s position is incorrect. The Fowler’s position is not suitable for oral hygiene in an unconscious client as it increases the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Suction the trachea.
Choice A rationale:
The practical nurse (PN) should ensure the ready availability of equipment to perform tracheal suctioning for a client who requires seizure precautions. Seizures can sometimes cause excessive salivation or even vomiting, which may lead to the obstruction of the airway. Suctioning the trachea helps in quickly clearing any secretions or vomitus from the airway, preventing potential respiratory compromise and ensuring the client's airway remains patent.
Choice B rationale:
Inserting a nasogastric tube is not directly related to seizure precautions. Nasogastric tubes are used for various purposes, such as decompression of the stomach, feeding, or administering medications. While it might be necessary in specific situations, it is not a priority when caring for a client on seizure precautions.
Choice C rationale:
Inserting a urinary catheter is also not directly related to seizure precautions. It is typically done for clients who have difficulty urinating on their own or for precise monitoring of urine output. Seizure precautions focus on the client's airway and safety during a seizure episode.
Choice D rationale:
Applying soft restraints is generally not recommended for clients on seizure precautions. Restraints should only be used as a last resort for clients who pose a risk to themselves or others during a seizure. The primary goal is to provide a safe environment and prevent injuries without restraining the client unless absolutely necessary.
Correct Answer is B
Explanation
The correct answer is choice B, Contact information for the client's next of kin. Choice A rationale:
Knowing the name of the funeral home to contact is not a priority during the admission assessment of a terminally ill client. While this information may eventually be necessary, the immediate focus should be on gathering essential medical and contact information.
Choice B rationale:
Collecting contact information for the client's next of kin is crucial during the admission assessment of a terminally ill client. In case of any emergencies or changes in the client's condition, the healthcare team needs to be able to reach the client's closest family member or legal representative promptly.
Choice C rationale:
Healthcare proxy documentation is essential for clients who have designated someone to make medical decisions on their behalf if they become incapacitated. While this information is significant, it may not be directly applicable to all terminally ill clients, as not all of them may have a designated healthcare proxy.
Choice D rationale:
Knowing the client's wishes regarding organ donation is important for ethical and legal reasons. However, it is not the most critical piece of information to collect during the initial admission assessment of a terminally ill client. Organ donation discussions can be sensitive and require a more appropriate time and setting. The focus during admission is on immediate medical needs and contact information for family or next of kin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.