A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Test for the presence of the client's gag reflex.

Lubricate the lips with petroleum jelly.

Place the client in the supine position.

Use a firm toothbrush for tooth and gum care.

Answer and Explanation

The Correct Answer is B

A.   Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B.   Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C.   Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D.   Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

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Correct Answer is ["1690"]

Explanation

To calculate the 8-hr fluid intake, convert all the measurements to milliliters (mL).

1 oz = 30 mL, so 6 oz of tea = 180 mL, 4 oz of apple juice = 120 mL, 8 oz of water = 240 mL, 3 oz of flavored gelatin = 90 mL, and 6 oz of broth = 180 mL.

Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL.

Round the answer to the nearest whole number: 1690 mL.

The nurse should document 1690 mL as the client's 8-hr fluid intake.

A. Hold the dropper 1/2 inch (1 cm) above the ear canal during administration. B. Place a cotton ball into the inner ear canal for 30 min following administration. C. Straighten the ear canal by pulling the auricle down and back prior to administration. D. Apply pressure to the nasolacrimal duct following administration.

Correct Answer is A

Explanation

A. Holding the dropper 1/2 inch (1 cm) above the ear canal during administration (option A) is indeed the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal, reducing the risk of contamination.
B. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client.

C. Straightening the ear canal by pulling the auricle down and back can make the medication trickle out of the ear. It should be held outward and upward.
D. Applying pressure to the nasolacrimal duct is a technique used for ophthalmic medications, not otic medications.

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A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1690"]

Explanation

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Correct Answer is A

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