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 C

Explanation

A. Controlled substances typically require a licensed nurse or provider to witness the wasting, not assistive personnel.
B. Wasted medication should be disposed of according to facility policies but not necessarily in a sharps container unless it is a sharp object.
C. Recording the amount of medication wasted on the controlled substance inventory record is a crucial step to maintain accurate documentation.
D. Returning the unused portion of a controlled substance to the pharmacy is not an appropriate action and goes against medication safety protocols. Controlled substances should be wasted and documented properly.

A. The client holds the cane on the affected side. B. The client keeps two points of support on the ground. C. The client advances the cane before moving the unaffected leg. D. The client supports his weight on both legs when moving the cane forward.

Correct Answer is A

Explanation

A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.

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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?

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