A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Use a stiff toothbrush to clean the client's teeth.
Turn the client on his side before starting oral care.
Use the thumb and index finger to keep the client's mouth open.
Apply petroleum jelly to the client's lips after oral care.
The Correct Answer is B
A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.
B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.
C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.
D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B. Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C. Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D. Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.
Correct Answer is A
Explanation
A. The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.
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