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

Correct answer: C

A. A client who has a venous stasis ulcer: This is less likely to cause a false positive result. While ulcers can bleed, the fecal occult blood test is designed to detect small amounts of blood in the stool, not necessarily blood from other sources like venous stasis ulcers.

B. A client who has peripheral hematomas: Peripheral hematomas are typically not related to the fecal occult blood test. They generally wouldn’t affect the results unless there was significant bleeding or if the hematomas were a result of an underlying bleeding disorder.

C. A client who underwent a barium swallow study: This is the most likely to cause a false positive result. Barium used in the study can sometimes appear as a false positive on the test due to its interference with the chemical reactions used to detect blood.

D. A client who takes an iron supplement: Iron supplements can actually cause a false negative result rather than a false positive because they may darken the stool and mask the presence of blood.

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

Correct Answer is B

Explanation

This action will help the client hear the nurse better by reducing competing sounds.

The nurse should also face the client when speaking, use short phrases, and communicate using paper and pen if needed.

Choice A is wrong because using short phrases alone is not enough to promote communication with a client who has hearing loss.

The nurse should also use other strategies such as decreasing background noise and facing the client when speaking.

Choice C is wrong because speaking in a loud voice can distort the sound and make it harder for the client to understand.

The nurse should speak clearly, slowly, and distinctly, but not shout.

Choice D is wrong because talking at a rapid rate can make it difficult for the client to follow the conversation.

The nurse should speak at a normal pace and pause between sentences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider’s office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result?

Correct Answer is C

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Correct Answer is B

Explanation

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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?