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. Raise the bed to waist level before moving the client. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Stand on the client’s stronger side when moving the client into the chair. D. Flex hips and knees when assisting the client to a standing position.

Correct Answer is D

Explanation

The correct answer is choice D. Flex hips and knees when assisting the client to a standing position.

Choice A rationale:

Raising the bed to waist level before moving the client is not recommended because it can increase the risk of falls and injuries. The bed should be at a height that allows the nurse to maintain proper body mechanics and ensure the client’s safety during the transfer.

Choice B rationale:

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain stability and control during the transfer.

Choice C rationale:

Standing on the client’s stronger side when moving the client into the chair is not the best practice. The nurse should stand on the client’s weaker side to provide support and prevent the client from falling towards their weaker side.

Choice D rationale:

Flexing hips and knees when assisting the client to a standing position is correct. This technique helps the nurse maintain proper body mechanics, reduces the risk of injury, and provides better support to the client during the transfer.

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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?