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 C

Explanation

When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.

This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.

Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.

Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.

Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.

A. Placing a client in restraints without having a healthcare provider's order. B. Administering the medication to a client behind a closed curtain. C. Enlisting security personnel to assist with restraining the client. D. Informing a client that the medication being administered is a sedative.

Correct Answer is A

Explanation

Placing a client in restraints without having a healthcare provider’s order.

It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.

Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.

Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.

Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.

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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?

Nursing Test Bank

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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?

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