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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s true that a nasal cannula allows the patient to remove it for a while when it gets uncomfortable, this is not the primary reason for using a nasal cannula. The main purpose of a nasal cannula is to deliver oxygen.
Choice B rationale
A nasal cannula delivers the low concentration of oxygen that the patient needs. It is designed to provide a specific amount of oxygen, and the flow rate can be adjusted as needed.
Choice C rationale
While a nasal cannula does deliver a specific concentration of oxygen, it does not do so constantly. The amount of oxygen delivered can vary depending on the patient’s breathing rate and depth.
Choice D rationale
A nasal cannula does not deliver the highest concentration of oxygen possible. Other devices, such as non-rebreather masks, can deliver higher concentrations of oxygen.
Correct Answer is B
Explanation
Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale
Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.