A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Using an oral care sponge swab moistened with cool water to clean the client's mouth.

Wearing clean gloves to perform mouth care for the client.

Lowering the side rail on the side of the bed where they will stand to perform mouth care.

Using two gloved fingers to open the client's mouth for cleaning.

Answer and Explanation

The Correct Answer is D

The correct answer is d. Using two gloved fingers to open the client’s mouth for cleaning. This action is unsafe as it risks injury to both the AP and the client. A padded tongue blade should be used instead.

Choice A reason:

Using an oral care sponge swab moistened with cool water to clean the client’s mouth is appropriate. Oral care sponge swabs are designed to clean the mouth gently and effectively, especially for unconscious patients.

Choice B reason:

Wearing clean gloves to perform mouth care for the client is a standard precaution to prevent infection. Gloves protect both the caregiver and the patient from potential infections.

Choice C reason:

Lowering the side rail on the side of the bed where they will stand to perform mouth care is necessary to safely access the patient. It allows the AP to perform the task without straining or risking injury.

Choice D reason:

Using two gloved fingers to open the client’s mouth for cleaning is unsafe. This method can cause injury to the AP if the patient bites down reflexively. A padded tongue blade should be used to safely open the mouth.

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Correct Answer is B

Explanation

Choice A reason: Broccoli is a good source of vitamin K, which is essential for blood clotting. However, it also contains vitamin C, which can interfere with the action of warfarin, a medication used to treat Westerly syndrome. Therefore, broccoli should be consumed in moderation and with caution.

Choice B reason: Bananas are high in potassium, which can affect the heart rhythm and cause arrhythmias in people with Westerly syndrome. Therefore, bananas should be avoided or limited in the diet.

Choice C reason: Mushrooms are low in vitamin K and do not interact with warfarin. They are also a good source of protein, fiber, and antioxidants. Therefore, mushrooms can be safely consumed by people with Westerly syndrome.

Choice D reason: Popcorn is high in sodium, which can increase blood pressure and worsen the symptoms of Westerly syndrome. Therefore, popcorn intake should be limited or avoided.

A. Talk at a rapid rate. B. Use short phrases. C. Decrease background noise. D. Speak in a loud voice.

Correct Answer is C

Explanation

Choice A reason: Talking at a rapid rate is not a good action to promote communication with a client who has hearing loss. Talking too fast can make it harder for the client to follow the conversation, lip-read, or use hearing aids. The nurse should talk at a normal rate and pause between sentences.

Choice B reason: Using short phrases is not a good action to promote communication with a client who has hearing loss. Using short phrases can make the message unclear, incomplete, or condescending. The nurse should use complete sentences and avoid jargon, slang, or abbreviations.

Choice C reason: Decreasing background noise is a good action to promote communication with a client who has hearing loss. Background noise can interfere with the client's ability to hear and understand the nurse. The nurse should reduce or eliminate any sources of noise, such as TV, radio, or other people, and choose a quiet and well-lit place to talk.

Choice D reason: Speaking in a loud voice is not a good action to promote communication with a client who has hearing loss. Speaking too loud can distort the sound, cause discomfort, or offend the client. The nurse should speak in a clear and natural voice and adjust the volume according to the client's feedback.

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A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

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