A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

Use a stiff toothbrush to clean the client's teeth.

Apply petroleum jelly to the client's lips after oral care.

Use the thumb and index finger to keep the client's mouth open.

Answer and Explanation

The Correct Answer is A

A.   This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B.   Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C.   Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D.   Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

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Correct Answer is A

Explanation

A. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

A. Encourage the client to cough and deep breathe. B. Obtain the client's temperature. C. Encourage the client to increase oral fluids. D. Provide chest percussion on the client.

Correct Answer is A

Explanation

A. This action helps the client to clear pulmonary secretions and improve ventilation. Coughing and deep breathing exercises are essential for maintaining airway patency and preventing complications such as atelectasis and respiratory distress.
B. Monitoring the client's temperature is important to assess for fever, which can indicate infection severity or response to treatment. However, in a client actively coughing up secretions, immediate interventions to promote airway clearance take precedence over obtaining temperature.
C. Adequate hydration can help liquefy pulmonary secretions, making them easier to expectorate. However, this action is secondary to promoting effective coughing and deep breathing to clear secretions already present in the airways.

D. Chest percussion can help loosen and mobilize secretions in the lungs. However, this intervention requires assessment of the client's respiratory status and may not be appropriate as the first action without first assessing the client's tolerance and condition.

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A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

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