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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. An elevation in the red blood cell (RBC) count is not a specific indication of infection. It primarily reflects oxygen-carrying capacity.
B. An elevation in the white blood cell (WBC) count is an indication of infection. When the body is fighting an infection, the number of white blood cells increases as part of the immune response.
C. Potassium is an electrolyte and is not a specific marker for infection. Abnormal potassium levels may indicate a variety of conditions, but they do not directly indicate infection.
D. Blood urea nitrogen (BUN) is a marker of kidney function and is not a specific indicator of infection. Elevated BUN levels can be seen in various kidney and non-kidney-related conditions.

A. inguinal canal B. knee C. lower third of the tibia D. dorsal aspect of the foot

Correct Answer is C

Explanation

A. Inguinal canal is not the correct location for assessing the posterior tibial pulse. This area is associated with the femoral pulse.
B. The knee is not the correct location for assessing the posterior tibial pulse. This area is not directly related to the posterior tibial pulse.
C. The lower third of the tibia, anterior aspect is the correct location for palpating the posterior tibial pulse. This pulse can be found on the inside of the ankle, slightly below and behind the medial malleolus.
D. Dorsal aspect of the foot is where the dorsalis pedis pulse is located, not the posterior tibial pulse.

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A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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