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

According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.

It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.

Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.

Choice A is wrong because chlorhexidine is not effective against C. difficile spores.

Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.

Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.

Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.

Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.

Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.

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 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?