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 B

Explanation

The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.

Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.

Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.

Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.

A. Remind the UAP to locate the thermometer before gently inserting the ear. B. Demonstrate the correct technique for pulling the client's auricle up and back. C. Advise the UAP to hold the thermometer securely in place to obtain the measurement. D. Use positive reinforcement to affirm that the procedure being performed correctly.

Correct Answer is D

Explanation

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

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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

Naxlex Comprehensive Predictor Exams

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

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?