The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Suctions secretions from the posterior pharynx.

Tests for a gag reflex before performing oral care.

Places the client in a supine position.

Uses an oral airway to keep the teeth apart.

Answer and Explanation

The Correct Answer is C

A. Suctions secretions from the posterior pharynx:

Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.

B. Tests for a gag reflex before performing oral care:

Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.

C. Places the client in a supine position:

Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.

D. Uses an oral airway to keep the teeth apart:

Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.

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Correct Answer is C

Explanation

Correct answer: C

A. Irrigate the nasogastric tube with water:

This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.

B. Perform oropharyngeal suctioning:

While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..

C. Elevate the head of bed 45 degrees:

The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.

D. Review the advance directive document:

Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.

A. Observe the client's body language. B. Ask the client for learning feedback. C. Provide client focused information. D. Reinforce key points with the client.

Correct Answer is B

Explanation

A. Observe the client's body language:

This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.

B. Ask the client for learning feedback:

This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.

C. Provide client-focused information:

This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.

D. Reinforce key points with the client:

This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.

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The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is B

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