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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Muscle strengthening exercises may be appropriate, but vitamin D3 is a more immediate concern for addressing bone and muscle symptoms.

B. Clients with extensive burns may have vitamin D deficiencies due to changes in metabolism, diet, or lack of sunlight exposure. Vitamin D3 is essential for calcium absorption and bone health, which is why this client’s symptoms of bone pain and muscle weakness suggest a need for supplementation.

C. Progressive range of motion exercises are beneficial for mobility but should not be prioritized over addressing nutritional deficiencies.

D. Skin exposure to sunlight without sunscreen is not recommended for this client due to their burn history and potential for further skin damage.

A. Keep the room brightly lit while providing care. B. Monitor for change in speech. C. Report any change in level of consciousness. D. Minimize verbal interaction with the client. E. Avoid dropping side rails or abruptly closing the door.

Correct Answer is ["B","C","E"]

Explanation

A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client.

B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status.

C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse.

D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication.

E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Correct Answer is B

Explanation

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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