ATI PN FUNDAMENTALS UPDATED 2023
ATI PN FUNDAMENTALS UPDATED 2023 ( 41 Questions)
A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?
Using an oral care sponge swab moistened with cool water to clean the client's mouth is an appropriate action by the AP, as it helps to remove debris and bacteria from the oral cavity. It does not require intervention by the nurse.
Wearing clean gloves to perform mouth care for the client is an appropriate action by the AP, as it protects the AP and the client from potential infection. It does not require intervention by the nurse.
Lowering the side rail on the side of the bed where they will stand to perform mouth care is an inappropriate action by the AP, as it increases the risk of the client falling from the bed. It requires intervention by the nurse, who should instruct the AP to keep the side rails up at all times and use a tilt table or a pillow to support the client's head.
Using two gloved fingers to open the client's mouth for cleaning is an appropriate action by the AP, as it allows the AP to access the oral cavity without causing injury to the client. It does not require intervention by the nurse.
Choice A reason: Using an oral care sponge swab moistened with cool water to clean the client's mouth is an appropriate action by the AP, as it helps to remove debris and bacteria from the oral cavity. It does not require intervention by the nurse.
Choice B reason: Wearing clean gloves to perform mouth care for the client is an appropriate action by the AP, as it protects the AP and the client from potential infection. It does not require intervention by the nurse.
Choice C reason: Lowering the side rail on the side of the bed where they will stand to perform mouth care is an inappropriate action by the AP, as it increases the risk of the client falling from the bed. It requires intervention by the nurse, who should instruct the AP to keep the side rails up at all times and use a tilt table or a pillow to support the client's head.
Choice D reason: Using two gloved fingers to open the client's mouth for cleaning is an appropriate action by the AP, as it allows the AP to access the oral cavity without causing injury to the client. It does not require intervention by the nurse.