A client requires complete care with ADL's. Before providing oral care, the nurse should assess for which of the following?

Presence of pain

Presence of saliva

Gag reflex

Condition of the skin

Answer and Explanation

The Correct Answer is C

C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.

A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.

B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).

D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.

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Correct Answer is A

Explanation

A. This statement indicates an understanding of hospice care because hospice typically involves discontinuing aggressive treatments such as chemotherapy, radiation, or surgeries that are aimed at curing the cancer. Instead, the focus shifts to palliative care to manage symptoms and improve quality of life.

B. This statement suggests the client may not fully understand hospice care. In hospice, the emphasis is on managing symptoms in the home setting with the support of hospice nurses and caregivers. Calling 911 for symptom management contradicts the philosophy of hospice, which is to avoid aggressive interventions and hospitalizations.

C. This statement indicates a misunderstanding of hospice care. Hospice care focuses on comfort and quality of life rather than rehabilitative services such as physical therapy. In hospice, the care provided is primarily palliative and supportive rather than rehabilitative.

D This statement would indicate a misunderstanding of hospice care. In hospice, the prognosis is typically a life expectancy of six months or less if the disease follows its natural course. Hospice care is provided when curative treatments are no longer effective or desired, and the focus is on comfort rather than prolonging life.

A. Bronchovesicular B. Vesicular C. Bronchial D. Crackles

Correct Answer is B

Explanation

B. Heard over most of the lung fields, except for the major bronchi and the trachea.

Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.

A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.

C. Heard over the trachea and larynx.

Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.

D. Crackles are abnormal breath sounds that can be fine or coarse.

Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.

Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.

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A client requires complete care with ADL's. Before providing oral care, the nurse should assess for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has advanced cancer has been placed on hospice care, and the nurse is helping the client to understand what that means. Which statement made by the client indicates that teaching was effective? "I will:

Correct Answer is A

Explanation

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Correct Answer is B

Explanation

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