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?
Enroll the UAP in a hospital education class on conducting safe client care.
Praise the UAP for doing the oral hygiene but encourage family participation.
Tell the UAP to continue because the unconscious client is positioned safely.
Stop the procedure and tell the UAP to place the client in a Fowler's position.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Enrolling the UAP in a hospital education class on conducting safe client care is not an immediate response and does not address the current situation. It may be a longer-term solution for ongoing education.
Choice B rationale: Praising the UAP for performing oral hygiene and encouraging family participation does not address the immediate safety concern of the procedure being performed correctly.
Choice C rationale: Telling the UAP to continue because the unconscious client is positioned safely is incorrect. The client should not be in a flat side-lying position as it increases the risk of aspiration during oral hygiene.
Choice D rationale: Stopping the procedure and telling the UAP to place the client in a Fowler's position is correct. The Fowler's position helps maintain an open airway and reduces the risk of aspiration during oral hygiene in an unconscious client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.
Choice A rationale:
Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.
Choice B rationale:
Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.
Choice C rationale:
Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.
Choice D rationale:
For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
- A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
- A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
- A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
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