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 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.

A. Obtain apical and radial rates simultaneously. B. Palpate pulses in the lower extremities. C. Check blood pressure in left and right arms. D. Compare the pulse strength in upper extremities.

Correct Answer is A

Explanation

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

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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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