The nurse is planning to provide mouth care to an unconscious client.
Which statement is accurate for implementing mouth care to this client?

Brushing an unconscious client's teeth should be avoided.

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

Unconscious clients need less frequent mouth care than conscious clients.

Positioning the unconscious client upright is the best method because they are not eating or drinking.

Answer and Explanation

The Correct Answer is B

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

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Correct Answer is D

Explanation

A well-approximated incision means that the edges of the wound are close together and aligned properly, which is a sign that the surgical incision is healing properly.

Choice A is incorrect because eschar and slough in the wound are not signs of proper healing.

Choice B is incorrect because beety red granulation tissue is not a sign of proper healing.

Choice C is incorrect because erythema and serosanguineous drainage are not signs of proper healing.

A. "Tell me about the visit with your significant other. I can see that you are feeling lonely." B. "I noticed that you were more insulting to the evening group after your significant other left. Why is that?" C. "Why don't you try to make some friends here so you won't feel so lonely?" D. "It sounds like your visit with your significant other was important to you. How did it go?" E. None F. None

Correct Answer is D

Explanation

Choice D
This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.

Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.

Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.

Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.

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The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is D

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Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?

Correct Answer is D

Explanation

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The nurse is planning to provide mouth care to an unconscious client.
Which statement is accurate for implementing mouth care to this client?