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 D

Explanation

The total volume to infuse is 1,000 ml over 8 hours, which calculates to a rate of 125 ml/hour (1,000 ml ÷ 8 hr).

By 1400, the client has already received 500 ml (since there is 500 ml remaining in the IV bag).
The infusion has been running for 4 hours (from 1000 to 1400), which means the nurse has infused 500 ml (125 ml/hour × 4 hours).
Since there are 500 ml remaining in the bag, it will take another 4 hours to complete the infusion (500 ml ÷ 125 ml/hour).
Therefore, if the nurse administers the next bag immediately after the current one runs out, it will be at 1800 (1400 + 4 hours).
However, the timing of administering the next bag depends on when the current bag will run out. Since there is still 500 ml remaining, it will take 4 more hours until the IV solution runs out, which is at 1800.

A. Measurement of residual urine after urination B. An open perineal wound C. Relief of urinary retention D. Convenience for the nursing staff or the client's family E. routine acquisition of a urine specimen

Correct Answer is ["A","B","C"]

Explanation

A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.

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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

A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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