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 B

Explanation

Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale

Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.

Correct Answer is ["2 ."]

Explanation

Step 1: Identify the prescribed dose and the available dose. The prescribed dose is 500 mg and the available dose is 250 mg per tablet.

Step 2: Use the formula for calculating the number of tablets: (Prescribed dose ÷ Available dose) = Number of tablets.
Step 3: Substitute the values into the formula: (500 mg ÷ 250 mg/tablet) = 2 tablets. So, the nurse should administer 2 tablets.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing home safety information with an older adult client. Which of the following statements indicates that the client needs further instruction?

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A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer?

Correct Answer is ["2 ."]

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