A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following tasks should the nurse instruct the family to perform first?

Place the client in a side-lying position.

Clean the client's mouth with foam swabs.

Position an emesis basin under the client's chin.

Place a towel under the client's head.

Answer and Explanation

The Correct Answer is A

A. Place the client in a side-lying position: Positioning the client on their side is the priority because it helps maintain airway safety and prevents aspiration during oral care. This step must be done first before beginning the cleaning process.

B. Clean the client's mouth with foam swabs: Oral cleaning is important to reduce bacterial growth and maintain comfort, but it should only be performed after the client is positioned safely to avoid aspiration.

C. Position an emesis basin under the client's chin: The emesis basin helps catch secretions and cleaning solution, but this is a supportive measure that comes after ensuring the client’s airway protection through proper positioning.

D. Place a towel under the client's head: A towel provides comfort and helps keep linens dry, but it is a secondary measure. Airway protection through positioning always takes priority before comfort and cleanliness.

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Correct Answer is D

Explanation

A. Request additional information about the caller's relationship to the client: Even if the caller provides details about their relationship, this does not guarantee that the client has authorized disclosure. Verifying identity alone is not sufficient to maintain confidentiality.

B. Provide a general update about the client's condition over the telephone: Giving any medical information, even general, without the client’s consent is a breach of confidentiality and violates HIPAA regulations.

C. Refer the family member to the client's provider for the update: Referring the caller to the provider still risks confidentiality concerns if the client has not given explicit permission. Authorization must come from the client before anyone shares details.

D. Encourage the family member to contact the client directly for information: This maintains client confidentiality by ensuring that health information is shared only if the client chooses to disclose it. It protects privacy while respecting the client’s autonomy.

A. Schedule the client as the last surgery of the day. B. Notify ancillary departments of the client's allergy. C. Label the surgical suite as latex-free. D. Provide powdered gloves for the staff's use. E. Ensure a latex allergy cart is available.

Correct Answer is ["B","C","E"]

Explanation

A. Schedule the client as the last surgery of the day: Clients with latex allergy should ideally be scheduled as the first surgery of the day to minimize exposure to latex particles that may accumulate in the air and environment. Scheduling last increases exposure risk.

B. Notify ancillary departments of the client's allergy: Informing all relevant departments, such as pharmacy, radiology, and laboratory services, ensures that latex-free supplies are used consistently throughout the client’s care. This prevents accidental exposure to latex-containing products.

C. Label the surgical suite as latex-free: Clearly labeling the operating room reduces the risk of staff inadvertently bringing in latex products. It promotes team-wide awareness and helps maintain a safe surgical environment for the client.

D. Provide powdered gloves for the staff's use: Powdered latex gloves are contraindicated because they release latex proteins into the air, which increases the risk of allergic reactions. Only non-latex, powder-free gloves should be provided.

E. Ensure a latex allergy cart is available: Having a latex allergy cart stocked with latex-free supplies ensures that all necessary items are available during the procedure. This reduces delays and eliminates the need to search for suitable equipment during surgery.

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A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following tasks should the nurse instruct the family to perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Correct Answer is D

Explanation

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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