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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Systematic reviews are considered Level I evidence in the hierarchy of evidence in evidence-based practice (EBP). Systematic reviews involve the rigorous and comprehensive synthesis of multiple research studies on a specific topic. This approach minimizes bias and provides the highest level of evidence for making clinical decisions. Systematic reviews typically follow a structured methodology and offer a critical analysis of the existing literature, making them a strong foundation for EBP.
Choice B rationale:
Credible websites are not considered Level I evidence. While some websites may contain reliable information, they vary in quality, and the credibility of the source must be carefully assessed. Relying solely on websites is not the most robust approach in EBP, as it lacks the rigorous systematic review and critical appraisal process of Level I evidence.
Choice C rationale:
Expert opinions are not considered Level I evidence. While expert opinions can be valuable, they are often based on individual experiences and interpretations rather than systematic research. Expert opinions are generally considered lower in the hierarchy of evidence compared to systematic reviews and other forms of research evidence.
Choice D rationale:
Qualitative studies are not considered Level I evidence. Qualitative studies provide valuable insights into the experiences, perceptions, and meanings associated with a particular phenomenon. However, they are typically ranked lower in the hierarchy of evidence compared to systematic reviews and quantitative research studies. Qualitative studies are more appropriate for addressing research questions related to subjective experiences and understanding the "why" and "how" of a phenomenon.
Correct Answer is D
Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
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