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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale
Antimicrobial dressings are typically used for wounds that are infected or at high risk of infection. A stage I pressure ulcer, which involves intact skin with non-blanchable redness, would not typically require an antimicrobial dressing.
Choice B rationale
Wet-to-dry dressings are used for mechanical debridement of wounds with necrotic tissue. A stage I pressure ulcer does not involve necrotic tissue, so this type of dressing would not be appropriate.
Choice C rationale
Transparent dressings are often used for stage I pressure ulcers. They provide a protective layer over the wound, promoting a moist environment and facilitating the healing process.
Choice D rationale

Dry, sterile dressings are typically used for wounds that need to be kept dry. A stage I pressure ulcer benefits from a moist healing environment, which can be provided by a transparent dressing.

A. A client who has community-acquired pneumonia with copious respiratory secretions B. A client who has AIDS and is coughing up blood C. A client who has Guillain-Barré syndrome and is on a ventilator D. A client who has bronchitis and a tracheostomy

Correct Answer is A

Explanation

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Correct Answer is C

Explanation

A nurse is assisting a charge nurse with room assignments. There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

Correct Answer is A

Explanation

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