A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?
Turn the patient on their side before starting oral care.
Apply petroleum jelly to the patient’s lips after oral care.
Use the thumb and index finger to keep the patient’s mouth open.
Use a stiff toothbrush to clean the patient’s teeth.
The Correct Answer is A
Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Skim milk is not acceptable for a client on a clear liquid diet. Clear liquid diets only include liquids that you can see through, and milk is not a clear liquid.
Choice B rationale
Carrot juice is not acceptable for a client on a clear liquid diet. While it is a liquid, it is not clear, and therefore does not meet the criteria for a clear liquid diet.
Choice C rationale
Grape juice is acceptable for a client on a clear liquid diet, as long as it is without pulp. Clear fruit juices are typically included in a clear liquid diet.
Choice D rationale
Chicken broth is acceptable for a client on a clear liquid diet. Broths are clear liquids and are often included in a clear liquid diet to provide some savory flavor.
Correct Answer is C
Explanation
Choice A rationale
Mycoplasmal pneumonia, also known as walking pneumonia, is typically not an airborne disease. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice B rationale
Scarlet fever is caused by group A Streptococcus bacteria, which are spread through respiratory droplets. Standard precautions, including the use of a surgical mask, are usually sufficient when caring for these patients.
Choice C rationale
Tuberculosis is an airborne disease. Healthcare providers should wear an N95 respirator when caring for a client with tuberculosis to protect themselves from inhaling the bacteria.
Therefore, Choice C is the correct answer.
Choice D rationale
Scabies is caused by a mite and is spread through direct skin-to-skin contact. It is not an airborne disease, so an N95 respirator is not necessary when caring for a client with scabies.
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