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

The correct answer is B.

Choice A reason: Using a stiff toothbrush to clean the client’s teeth is not recommended. A stiff toothbrush can cause damage to the gums and teeth, especially in clients who may have sensitive oral tissues due to medications or medical treatments.

Choice B reason: Turning the client on his side before starting oral care is the most appropriate action. This is to prevent aspiration, especially in immobile clients who may have difficulty swallowing or clearing their throat.

Choice C reason: Using the thumb and index finger to keep the client’s mouth open is not recommended. This could be uncomfortable or even harmful for the client. Instead, a padded tongue blade could be used if necessary, but only with extreme caution and the client’s comfort in mind.

Choice D reason: Applying petroleum jelly to the client’s lips after oral care is also a good practice. This helps to prevent dryness and cracking of the lips, which can be a common problem for hospitalized patients, especially those who are dehydrated or receiving oxygen therapy. However, when compared to choice B, it is not as critical in terms of immediate safety concerns.

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Correct Answer is B

Explanation

Choice A rationale:

SDOH are not determined by an individual's ethnic background. SDOH encompass a wide range of factors beyond ethnicity that affect an individual's well-being, including social, economic, and environmental factors.

Choice B rationale:

SDOH are conditions in an individual's environment that affect their well-being. This is the correct answer. Social Determinants of Health (SDOH) refer to the conditions in which people are born, grow, live, work, and age, and how these conditions impact their physical and mental well-being. These conditions include factors such as income, education, employment, social support, and access to healthcare.

Choice C rationale:

Identifying SDOH does not increase disparities in healthcare. In fact, recognizing and addressing SDOH can help reduce health disparities by providing more equitable access to resources and services for underserved populations.

Choice D rationale:

While psychological factors can be important determinants of health, they are not typically considered part of the social determinants of health. SDOH primarily focus on external factors related to an individual's environment and socioeconomic conditions.

A. Anticipate removing the restraints every 4 hr. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints using a quick-release tie. D. Secure the restraints to the lowest bar of the side rail.

Correct Answer is C

Explanation

The correct answer is Choice C. Secure the restraints using a quick-release tie.

Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.

Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.

Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.

Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.

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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?