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The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. Performs hand hygiene and applies clean gloves
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: A 15-degree HOB increases aspiration risk; it should be 30-45 degrees. Towels go in regular laundry, not biohazard. Other actions are correct.
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The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?
- A. BUN level
- B. Prothrombin time
- C. Creatinine level
- D. Viral load
Correct Answer: B
Rationale: Prothrombin time assesses clotting, critical post-oral surgery to monitor bleeding risk. BUN and creatinine assess kidney function, and viral load is irrelevant.
The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
- A. Instructs the client to tilt the head backward when drinking.
- B. Reminds the client to assume a chin-down position.
- C. Provides rest periods as needed during the meal.
- D. Positions the client upright for 30-60 minutes after a meal.
- E. Positions the head of the bed at a 45-degree angle during the meal.
Correct Answer: A
Rationale: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?
- A. Air humidifier
- B. Inner cannula
- C. Nasal cannula oxygen
- D. Tracheostomy brush
Correct Answer: B
Rationale: An inner cannula is essential for tracheostomy care to replace or clean it if obstructed. Humidifiers, nasal cannulas, and brushes are not critical bedside items.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
- A. Perform range of motion with the client's left leg.
- B. Obtain the client's temperature.
- C. Assess the client for pain.
- D. Administer prescribed oxycodone-acetaminophen.
Correct Answer: C
Rationale: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.