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","C","D"]

Explanation

A. Warfarin is not administered in this situation unless directed by a provider; the priority is addressing possible bleeding.
B. Reviewing the last PTT results is important to assess the effectiveness of heparin and monitor for potential bleeding complications.
C. Assessing the characteristics of pain can help determine if the client is experiencing gastrointestinal bleeding, which is a concern with heparin therapy.
D. Monitoring for blood in the stool is crucial, as tarry stools indicate possible gastrointestinal bleeding, a known complication of anticoagulation therapy.
E. Auscultating bowel sounds is important but does not directly address the potential complication of gastrointestinal bleeding, which is the priority in this situation.

A. Expose client's extremities and apply ice packs to axilla. B. Recheck all vital signs including core temperature. C. Continue to monitor vital signs every hour. D. Apply oxygen via nasal prongs at 4 L/minute. E. Page the admitting anesthesiologist STAT

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

Explanation

A. Ice packs can be used but are not the first priority.
B. Rechecking core temperature confirms the severity of hyperthermia.
C. Monitoring hourly is insufficient for a rapidly rising temperature.
D. Oxygen helps prevent hypoxia from hypermetabolic states.
E. Malignant hyperthermia is a medical emergency requiring immediate intervention.

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

Explanation

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

Explanation

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