The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Auscultate breath sounds after client swallows.

Offer small sips of water through a straw.

Use a penlight to observe back of oral cavity.

Place tongue blade on back half of tongue.

Answer and Explanation

The Correct Answer is D

Choice A reason: Auscultating breath sounds after swallowing assesses lung function and aspiration risk but does not directly evaluate the gag reflex. The gag reflex, mediated by cranial nerves IX and X, is tested by stimulating the posterior pharynx. This method is indirect and less specific, as it relies on swallowing, which may not trigger the reflex in a weak client.

Choice B reason: Offering small sips of water tests swallowing but not the gag reflex specifically. Swallowing involves multiple cranial nerves, but the gag reflex requires direct stimulation of the posterior pharynx. In a lethargic client, this could risk aspiration, and it does not provide a clear assessment of the reflex needed for safe mouth care.

Choice C reason: Using a penlight to observe the oral cavity assesses structure but not function. The gag reflex requires tactile stimulation of the posterior pharynx to elicit a response. Visual inspection cannot confirm the reflex’s presence, which is critical to ensure safety during mouth care in a weak, lethargic client.

Choice D reason: Placing a tongue blade on the back half of the tongue directly stimulates the posterior pharynx, triggering the gag reflex if intact. This tests cranial nerves IX and X, ensuring the client can protect their airway during mouth care. In a lethargic client, this method is safe, specific, and essential to prevent aspiration, aligning with standard nursing practice.

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Correct Answer is C

Explanation

Choice A reason: Chronic insomnia and atrial fibrillation are not direct risk factors for sleep apnea. Warfarin treats clotting but does not affect airway obstruction. Sleep apnea is linked to obesity and anatomical factors, making this client less likely to require regular nighttime assessments compared to an obese, hypertensive client.

Choice B reason: Restless leg syndrome and COPD affect sleep and breathing but are not primary sleep apnea risk factors. COPD causes chronic airflow limitation, not intermittent airway collapse like apnea. Obesity is a stronger predictor, making the obese client with comorbidities a higher priority for regular sleep apnea assessments.

Choice C reason: Obesity, diabetes, and hypertension are strongly associated with obstructive sleep apnea, as excess weight narrows airways, causing intermittent collapse during sleep. Older adults are at higher risk due to reduced muscle tone. Regular nighttime assessments for snoring or apneic episodes are critical to detect and manage this condition, per evidence-based guidelines.

Choice D reason: A bleeding ulcer, high stress, and flurazepam use may disrupt sleep but are not specific to sleep apnea. Flurazepam, a sedative, may worsen undiagnosed apnea by relaxing airway muscles. Obesity remains a stronger risk factor, making the obese client with comorbidities the priority for regular apnea assessments.

A. Before changing assignments, determine which staff members have fitted particulate filter masks. B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. C. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

Correct Answer is B

Explanation

Choice A reason: Checking for staff with fitted N95 masks before reassigning tasks is time-consuming and unnecessary. Streptococcal pharyngitis spreads via large respiratory droplets, requiring only droplet precautions with a standard surgical mask, gloves, and eye protection. N95 respirators are reserved for airborne pathogens or aerosol-generating procedures, which are not indicated here. This action delays care and misallocates resources, as the UAP can safely respond with standard precautions.

Choice B reason: A standard face mask suffices for droplet precautions, as streptococcal pharyngitis is transmitted through large respiratory droplets, not fine aerosols. CDC guidelines endorse surgical masks, gloves, and eye protection for routine care of such patients. N95 masks are unnecessary unless aerosol-generating procedures occur. This option ensures immediate, safe care delivery while adhering to evidence-based infection control protocols.

Choice C reason: Sending the UAP for immediate N95 fitting is inefficient and unwarranted. The fitting process requires trained personnel and time, delaying patient care. Droplet precautions for streptococcal pharyngitis do not require N95 masks, as the pathogen is not airborne. This action overcomplicates the response, misaligns with CDC guidelines, and diverts focus from the patient’s immediate needs.

Choice D reason: Advising the UAP to use a standard mask for vital signs and later get fitted for an N95 for personal care is unnecessarily complex. Droplet precautions with a standard mask are sufficient for all routine interactions with this client. Requiring an N95 for personal care escalates precautions without scientific basis, delays care, and misuses resources.

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The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

Correct Answer is C

Explanation

An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is B

Explanation

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