HESI RN Exit Proctored Exam
Select All That Apply
The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction(s) should the nurse provide the UAP? Select all that apply.
Explanation & Rationale
A. Removing the gloved finger from the mouth is not necessarily appropriate unless the UAP is at risk of injury or if the client has a gag reflex that is causing a problem. B. Flex the client's neck forward helps facilitate drainage and reduces the risk of aspiration while providing oral care. C. Applying lubricant to the toothettes is not a priority in this scenario and may not be necessary. D. Turn the client's head to the side is an important safety measure to prevent aspiration of saliva or oral care products. E. Elevate the head of the bed to semi-Fowler's helps reduce the risk of aspiration by allowing gravity to assist in the drainage of fluids and secretions.
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