A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?
Vigorously brush the client’s teeth
Turn the client to the side
Hold the toothbrush at a 90-degree angle
Place two fingers in the client’s mouth
The Correct Answer is B
Turning the client to the side can help prevent aspiration while performing oral care on an unconscious patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
Correct Answer is A
Explanation
The nurse should choose a finger with good circulation, as indicated by a capillary refill time of less than 2 seconds, to obtain an accurate oxygen saturation reading.
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