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?
Explanation & Rationale
Choice A rationale: Enrollment in a remedial education class is unnecessary because the UAP is currently demonstrating the correct, evidence-based technique for providing oral care to an unconscious client to prevent aspiration. Choice B rationale: While positive reinforcement is beneficial, the primary focus should be on the clinical safety of the procedure. Encouraging family participation is secondary to ensuring the UAP maintains proper safety protocols. Choice C rationale: The side-lying position, combined with a towel and basin under the chin, allows secretions to drain out of the mouth by gravity. This is the safest position to prevent aspiration. Choice D rationale: Placing an unconscious client in Fowler's position increases the risk of the tongue falling back and secretions being aspirated into the lungs. The flat, side-lying position is much safer.