Question

The nurse is in the room of a client who is neutropenic. Which action by the nursing assistant, observed by the nurse, would indicate a need for action? A. Placing a Foley bag in the bed with the client when turning her B. Raising the head of the bed prior to feeding the client C. Adding pillows to the client's back area for support after turning and repositioning D. Providing mouth care to a client who is NPO

Short answer

Answer: Providing mouth care to a client who is NPO without using proper precautions.

Step-by-step solution

Option A: Placing a Foley bag in the bed with the client when turning her

A Foley bag collects urine from a catheter, and it should be placed on a hook and positioned below the level of the client's bladder to prevent backflow. Placing the bag on the bed is not an issue if it's positioned correctly. This action does not necessarily indicate a need for intervention.

Option B: Raising the head of the bed prior to feeding the client

Raising the head of the bed is a standard practice to minimize the risk of aspiration during feeding. This action is appropriate and does not indicate a need for intervention.

Option C: Adding pillows to the client's back area for support after turning and repositioning

Providing support to the client's back with pillows is a common practice to ensure comfort and proper positioning. This action does not indicate a need for intervention.

Option D: Providing mouth care to a client who is NPO (nothing by mouth)

Clients who are NPO still require mouth care to maintain oral hygiene and prevent infections. However, in neutropenic clients, extra precautions should be taken when providing mouth care to minimize the risk of infection or injury. For example, using a soft-bristled toothbrush or sponge swabs to avoid damage to the oral mucosa. This action may indicate a need for intervention if the nursing assistant is not using proper precautions. The correct answer is: D. Providing mouth care to a client who is NPO