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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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To administer a dose of 10 mg of olanzapine using 5 mg tablets, the nurse would need to give two (2) tablets
Correct Answer is A
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A. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.
C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.
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