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 B
Explanation
Hyperkalemia is a condition where there is an elevated level of potassium in the blood.
It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.
Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.
Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.
Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Correct Answer is B
Explanation
While drying the client’s feet, the nurse should emphasize the need to thoroughly dry between the toes.
Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete’s foot 1.
Choice C is not the answer because drying over the heels is not as important as drying between the toes 1.
Choice D is not the answer because drying around the ankles is not as important as drying between the toes 1.
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