The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

The correct answer is Choice A:

The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:

The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.

Choice B rationale:

This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.

Choice C rationale:

This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.

Choice D rationale:

This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.

The correct answer is choice B. Ineffective airway clearance.

Choice A rationale:

Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.