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 A

Explanation

Choice A reason: Receiving emotional support during the mother’s illness is a sign of understanding the teaching. Palliative care is a holistic approach that aims to improve the quality of life of clients and their families who are facing life-threatening illnesses. It provides physical, psychological, social, and spiritual support to address their needs and preferences.

Choice B reason: Providing resuscitation to the mother if necessary is a sign of misunderstanding the teaching. Palliative care focuses on relieving symptoms and suffering, not curing the illness or prolonging life. It respects the client’s wishes and goals of care, which may include a do-not-resuscitate (DNR) order or an advance directive.

Choice C reason: Not discussing the illness in the presence of the mother is a sign of misunderstanding the teaching. Palliative care encourages open and honest communication between the client and the family, as well as the health care team. It helps the client and the family cope with the illness, express their emotions and concerns, and make informed decisions.

Choice D reason: Not allowing the mother’s spiritual advisor to visit during this time is a sign of misunderstanding the teaching. Palliative care recognizes the importance of spirituality and religion for some clients and their families. It supports the client’s right to practice their faith and receive spiritual guidance and comfort from their chosen source.

A. I listen to my favorite music to take my mind off the pain. B. I learn to notice the sensation of muscle tension. C. I use focused breathing to control my pain. D. I think about my grandfather's farm to reduce pain.

Correct Answer is D

Explanation

Choice A reason: This is incorrect because listening to music is not a form of guided imagery, but a form of distraction, which may or may not be effective for pain management.

Choice B reason: This is incorrect because noticing the sensation of muscle tension is not a form of guided imagery, but a form of mindfulness, which may help with pain awareness, but not necessarily with pain relief.

Choice C reason: This is incorrect because using focused breathing is not a form of guided imagery, but a form of relaxation, which may help with pain reduction, but not with pain transformation.

Choice D reason: This is correct because thinking about a pleasant and meaningful place is a form of guided imagery, which involves using the imagination to create a positive and vivid sensory experience that can alter the perception of pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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