While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Unpleasant odor of the breath

White patches on the mucosa.

Gumline that has visibly receded.

Discoloration of several teeth.

Answer and Explanation

The Correct Answer is B

Choice A reason: While unpleasant odor can indicate poor oral hygiene or other health issues, it is not as urgent as some other findings.

Choice B reason: White patches on the mucosa can indicate an infection such as oral thrush, which requires medical treatment, making it the most important finding to act upon.

Choice C reason: A receding gumline is a concern for dental health but does not typically require immediate action.

Choice D reason: Discoloration of teeth can indicate various issues, including dietary habits or decay, but is not as immediately concerning as white patches on the mucosa. Bolded text indicates the correct answers and important information.

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Correct Answer is C

Explanation

Choice A reason: This response is inappropriate and dismissive of the sibling's concern and the client's need for communication assistance.

Choice B reason: Providing medical information to someone who is not an approved interpreter could breach confidentiality and privacy regulations.

Choice C reason: It is important to use an approved interpreter to ensure accurate and confidential communication of medical information.

Choice D reason: While the healthcare provider will share information, it is essential to use an approved interpreter to facilitate understanding and maintain confidentiality.

A. Praise the UAP for using standard precautions. B. Instruct the UAP to change gloves immediately. C. Request that an in-service program be scheduled on asepsis. D. Submit an adverse occurrence report to the unit manager.

Correct Answer is B

Explanation

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

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While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Correct Answer is B

Explanation

When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?