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.
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Related Questions
Correct Answer is C
Explanation
A. 3 mL syringe and a sterile needle.
This is incorrect. A sterile needle is unnecessary for administering an oral medication. Syringes with needles are used for injections, not for measuring or delivering oral medications.
B. One ounce medicine cup.
This is incorrect. While a medicine cup can be used for liquid medications, it is not precise for small volumes such as 2 mL. The graduations on a medicine cup are typically in larger increments, making it difficult to measure accurately.
C. 3 mL syringe.
This is correct. A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.
D. Tuberculin syringe.
This is incorrect. Although a tuberculin syringe can accurately measure small doses, it is designed for very small volumes, such as 1 mL or less. A 3 mL syringe is more appropriate for a 2 mL dose.
Correct Answer is C
Explanation
This will help determine if there is any residual urine left in the bladder after voiding.
Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.
Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.
Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.
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