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 D
A. Using a stiff toothbrush is not recommended for oral care, especially for clients who may have sensitive gums or mouth tissues. A soft-bristle toothbrush or disposable foam swabs are more appropriate for gentle oral care.
B. Turning the client on his side before starting oral care is a good practice to prevent aspiration and ensure proper positioning during the procedure. This allows any excess fluid or oral care products to drain out of the mouth.
C. Using the thumb and index finger to keep the client's mouth open can be uncomfortable and potentially harm the client's mouth. It's better to use a mouth prop or ask the client to open their mouth gently.
D. Applying petroleum jelly to the client's lips after oral care is a beneficial step to help moisturize and protect the lips, especially for clients who may be at risk for dryness or cracking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.
Correct Answer is D
Explanation
A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.
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