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 C

Explanation

A. Obtaining a 12-lead ECG is done after return of spontaneous circulation (ROSC), not during defibrillation.
B. Interrogating the pacemaker is important but is not the immediate priority during resuscitation.
C. Defibrillator pads should be placed at least 1 inch away from the pacemaker to prevent damage to the device and ensure effective defibrillation.
D. A doughnut magnet is used to deactivate pacemaker functions in cases like pacemaker-mediated tachycardia but is not relevant in ventricular fibrillation.

A. Sodium intake with meals and snacks affects the blood pressure. B. Elevated blood pressure must be anticipated and identified quickly. C. Blood pressure fluctuations means that the condition has become chronic. D. Hypotension leading to sudden shock can develop at any time.

Correct Answer is B

Explanation

A. Sodium intake with meals and snacks affects the blood pressure. While sodium can contribute to blood pressure increases, the primary reason for monitoring blood pressure in this case is to detect the kidney-related hypertension.

B. Elevated blood pressure must be anticipated and identified quickly. Blood pressure can increase significantly in acute glomerulonephritis due to fluid retention and kidney impairment. Frequent monitoring helps to identify and treat elevated blood pressure early, preventing complications.

C. Blood pressure fluctuations mean that the condition has become chronic. Acute glomerulonephritis typically causes fluctuating blood pressure, but this does not necessarily indicate chronic disease.

D. Hypotension leading to sudden shock can develop at any time. Hypotension is less common in acute glomerulonephritis compared to hypertension, making this response less accurate.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is B

Explanation

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