A nurse observes 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?

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

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.

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.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

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Correct Answer is C

Explanation

The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.

This is a positive sign of coping and adaptation after an amputation surgery.

Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.

The client needs to be encouraged to participate in self-care activities and rehabilitation.

Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.

The client may benefit from pain management, distraction techniques, and counseling.

Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.

The client needs emotional support and reassurance from the nurse and family members.

Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.

A. 1 medium fresh green pear. B. 1 small apple with skin. C. 1 small banana. D. 1 small pink grapefruit.

Correct Answer is D

Explanation

This food has the highest vitamin C content among the four options, with about 80 to 100 mg of vitamin C per fruit.

Vitamin C is a water-soluble vitamin that acts as an antioxidant and helps with wound healing, immune function, collagen synthesis, and iron absorption.

Choice A is wrong because 1 medium fresh green pear has only about 4 to 5 mg of vitamin C per fruit.

Pears are a good source of fiber and potassium, but not vitamin

C. Choice B is wrong because 1 small apple with the skin has only about 8 to 9 mg of vitamin C per fruit.

Apples are a good source of fiber and flavonoids, but not vitamin

C. Choice C is wrong because 1 small banana has only about 10 to 11 mg of vitamin C per fruit.

Bananas are a good source of potassium, magnesium, and vitamin B6, but not vitamin

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A nurse observes 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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A nurse is caring for a client who is 2 days postoperative following a below-theknee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

Correct Answer is C

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Correct Answer is D

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A nurse observes 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?