A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following tasks should the nurse instruct the family to perform first?
Place the client in a side-lying position.
Clean the client's mouth with foam swabs.
Position an emesis basin under the client's chin.
Place a towel under the client's head.
The Correct Answer is A
A. Place the client in a side-lying position: Positioning the client on their side is the priority because it helps maintain airway safety and prevents aspiration during oral care. This step must be done first before beginning the cleaning process.
B. Clean the client's mouth with foam swabs: Oral cleaning is important to reduce bacterial growth and maintain comfort, but it should only be performed after the client is positioned safely to avoid aspiration.
C. Position an emesis basin under the client's chin: The emesis basin helps catch secretions and cleaning solution, but this is a supportive measure that comes after ensuring the client’s airway protection through proper positioning.
D. Place a towel under the client's head: A towel provides comfort and helps keep linens dry, but it is a secondary measure. Airway protection through positioning always takes priority before comfort and cleanliness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,C,D,B,E
Explanation
A. Draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. Air is first drawn into the syringe for the intermediate-acting insulin to prevent creating a vacuum when withdrawing it later.
C. Inject the volume of air equal to the insulin dose from the short-acting insulin vial. Injecting air into the short-acting vial prevents vacuum formation and makes withdrawal easier.
D. Withdraw the prescribed amount of insulin from the short-acting insulin vial. The short-acting insulin is withdrawn first to avoid contaminating it with intermediate-acting insulin.
B. Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial. Air is injected into the intermediate-acting vial before withdrawal to facilitate drawing up the insulin.
E. Withdraw the prescribed amount of insulin from the intermediate-acting insulin vial. Finally, the intermediate-acting insulin is withdrawn, completing the mixture in the syringe.
Correct Answer is A
Explanation
A. 65 mL: The total liquid intake includes 30 mL of water used to flush the NG tube before the medication, 5 mL of medication instilled, and 30 mL of water used to flush the tube afterward. Adding these together gives 65 mL, which accurately reflects all fluids administered.
B. 5 mL: Documenting only the medication omits the water used for flushing, underrepresenting the client’s total fluid intake.
C. 35 mL: This amount accounts only for the post-flush water and medication, it ignores the pre-flush water, resulting in an inaccurate intake record.
D. 60 mL: This underestimates the total intake by failing to include all three components correctly; precise documentation is essential for fluid balance monitoring.
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