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. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.

B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.

C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.

D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor

A. please wear a mask B. please wear a gown C. dispose sharps here D. please wear gloves E. please wash your hands F. radiation inside

Correct Answer is ["A","B","D","E"]

Explanation

A. Wearing a mask helps protect against the transmission of airborne particles, which is important for preventing the spread of tuberculosis.
B. Wearing a gown can provide an additional barrier to prevent the transmission of infectious material.
C. Disposing sharps here is not directly related to tuberculosis precautions. This statement is more relevant for a sharps disposal container.
D. Wearing gloves is important to prevent direct contact with potentially contaminated surfaces.
E. Hand hygiene is crucial for infection control and should be emphasized for anyone entering or exiting the room of a client in isolation.
F. "Radiation inside" is not applicable to the isolation precautions for tuberculosis. This statement is unrelated to tuberculosis precautions and may cause confusion.

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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

Correct Answer is B

Explanation

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Correct Answer is ["A","B","D","E"]

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