Nokea
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. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
- 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: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.
You may also like to solve these questions
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
The nurse is presenting a home safety class on carbon monoxide toxicity to a group of older adults. Which statement would be appropriate for the nurse to make to the group of clients?
- A. Carbon monoxide is a gas that is gray in color and deadly.
- B. Carbon monoxide is a clear and odorless gas.
- C. Early signs of carbon monoxide toxicity include nose bleed and tremors.
- D. Carbon monoxide is a gas that smells like rotten eggs.
Correct Answer: B
Rationale: Carbon monoxide is a colorless, odorless gas, making detectors essential. It is not gray, does not smell like rotten eggs, and early signs include headache, not nosebleeds or tremors.
The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
- A. Keep the stretcher's side rails raised during the transfer
- B. Instruct the client to fold their arms over their chest
- C. Apply gloves and gown for this procedure
- D. Unlock the wheels on the stretcher and wheelchair
Correct Answer: B
Rationale: Instructing the client to fold their arms over their chest prevents interference with the lift and ensures safety. Side rails should be down, gloves/gown are not required, and wheels should be locked.
The nurse is preparing to obtain a capillary blood glucose from a client. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Hold the gauze on the client's finger after the specimen has been obtained.
- B. Turn the finger down to promote blood flow with gravity.
- C. Insert strip into monitor.
- D. Prick the side of the finger using the lancet.
- E. Verify and confirm that the code strip corresponds to the meter code.
- F. Disinfect the client's finger with an alcohol swab and allow it to dry.
- G. Read the client's blood glucose level on the monitor.
Correct Answer: E,F,C,D,B,A,G
Rationale: The correct order is: verify strip code (E), disinfect finger (F), insert strip (C), prick finger (D), promote blood flow (B), collect sample and apply gauze (A), read result (G). This ensures accuracy and safety.
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.