A nurse observes 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?

B Using an oral care sponge swab moistened with cool water to clean the client's mouth. A Lowering the side rail on the side of the bed where they will stand to perform mouth care. C Wearing clean gloves to perform mouth care for the client. D Using two gloved fingers to open the client's mouth for cleaning.