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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.
This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.
Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.
Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.
Correct Answer is C
Explanation
The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.
Choice A is not the answer because it is rude and unprofessional.
Choice B is not the answer because it does not address the issue of privacy and confidentiality.
Choice D is not the answer because it does not address the issue of privacy and confidentiality.
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