Today’s NCLEX-RN® question of the day presents a scenario where an RN is observing a student nurse as they provide oral care to a client. The client wears a CPAP mask to protect against sleep apnea. During the observation, the RN notices the student nurse making an error. Can you identify it, and explain how the student nurse’s mistake can be corrected?
A nurse is observing a student nurse preparing to provide oral care to a client wearing a nasal continuous positive airway pressure (CPAP) mask. Which observation by the nurse requires immediate intervention?
A. The mask is removed from the client before performing oral care.
B. A mint flavored moisturizer is applied to the lips after adjusting the CPAP mask.
C. The mouth is rinsed with water after brushing the teeth and before replacing the CPAP mask.
D. The student offers the client ice chips after replacing the CPAP mask.
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The correct answer to today’s NCLEX-RN® Question is…
D. The student offers the client ice chips after replacing the CPAP mask.
Rationale: Frequent oral care is essential because clients are at risk for impaired oral mucosal integrity due to the drying effect of the air. Care must be taken, though, to avoid aspiration while providing oral care, because the continuous air pressure increases the risk for aspiration. Removing the mask before providing oral care can help decrease the risk of aspiration. Leaving water in the mouth after rinsing or offering ice chips can increase the risk of aspiration.
Major takeaway
Ice-chips provided a client wearing a CPAP mask may lead to aspiration and should be avoided.
Incorrect answer explanations
A. The mask is removed from the client before performing oral care.
Rationale: The mask should be removed before oral care in order to prevent aspiration of oral secretions.
B. A mint-flavored moisturizer is applied to the lips after adjusting the CPAP mask.
Rationale: A mouth moisturizer can be applied safely with the nasal CPAP mask on or off. However, due to potential flammability, petroleum based moisturizers should be avoided if supplemental oxygen is being administered through the mask.
C. The mouth is rinsed with water after brushing the teeth and before replacing the CPAP mask.
Rationale: Rinsing of the mouth can be safely done when the mask is removed. Care should be taken to ensure there is no excess water in the mouth before the mask is reapplied.
References
Berman, A., Snyder, S. Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, Process, and practice. Boston, MA: Pearson.
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