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 B
Explanation
A. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.
Correct Answer is B
Explanation
A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.
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