The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction(s) should the nurse provide the UAP? Select all that apply.
Remove the gloved finger from the mouth.
Flex the client's neck forward.
Apply lubricant to the tootherte
Turn the client's head to the side.
Elevate the head of the bed to semi-Fowler's
Correct Answer : B,D,E
A. Removing the gloved finger from the mouth is not necessarily appropriate unless the UAP is at risk of injury or if the client has a gag reflex that is causing a problem.
B. Flex the client's neck forward helps facilitate drainage and reduces the risk of aspiration while providing oral care.
C. Applying lubricant to the toothettes is not a priority in this scenario and may not be necessary.
D. Turn the client's head to the side is an important safety measure to prevent aspiration of saliva or oral care products.
E. Elevate the head of the bed to semi-Fowler's helps reduce the risk of aspiration by allowing gravity to assist in the drainage of fluids and secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Watery diarrhea is a potential sign of Clostridium difficile (C. diff) infection, a serious and common complication associated with antibiotics like linezolid.
B. Nausea and headache are side effects but are less urgent than symptoms suggesting C. diff.
C. Increased fatigue is non-specific and may be related to the infection or the medication, but it is not as immediately concerning as diarrhea.
D. Yellow-tinged sputum is typical of pneumonia and does not indicate an urgent issue related to linezolid therapy.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E","dropdown-group-3":"E"}
Explanation
Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.
Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.
Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.
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