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:
In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.
Choice B rationale:
The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.
Choice C rationale:
The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.
Choice D rationale:
The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.
Correct Answer is B
Explanation
The correct answer is Choice B: A client who has a family history of breast cancer is scheduled for a mammogram.
Choice A rationale:
Receiving an influenza vaccination is an example of primary prevention, which aims to prevent the onset of disease.
Choice B rationale:
Scheduling a mammogram for a client with a family history of breast cancer is an example of secondary prevention. Secondary prevention involves the early detection and treatment of disease to reduce the impact of the disease. Mammograms help in the early detection of breast cancer, which can significantly improve treatment outcomes.
Choice C rationale:
Not scheduling tests for an asymptomatic client does not relate to secondary prevention. Secondary prevention involves screening and early detection of diseases in at-risk populations.
Choice D rationale:
Scheduling an echocardiogram for a client with heart failure is an example of tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness or injury that has lasting effects by helping patients manage long-term, complex health problems.
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