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 ["B","C","D","E"]

Explanation

A. Eye exams are generally recommended more frequently, especially for older adults, to monitor for age-related changes and conditions.
B. Women should have a clinical breast examination every year, in addition to mammograms as recommended by their healthcare provider.
C. Both men and women should have a colonoscopy periodically, depending on individual risk factors and age.
D. Regular hearing screenings are important for older adults, especially as age-related hearing loss may occur.
E. Testicular self-exams are recommended for men to detect any abnormalities early on.

A. Open the first flap of the sterile kit toward himself. B. Ensure that the sterile field is located below waist level. C. Place dry, sterile supplies 1/2 inch from the edge of the sterile field. D. Apply sterile gloves after preparing the sterile field.

Correct Answer is C

Explanation

A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.

C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.

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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

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