The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

Avoid using your fingers to open the mouth.

Apply moisturizer to the oral mucosa and lips.

Brush the teeth with a soft bristled toothbrush

Use a toothbrush with a suction attachment

Answer and Explanation

The Correct Answer is D

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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Correct Answer is A

Explanation

A. Placing an indwelling urinary catheter: Indwelling urinary catheters are a leading cause of catheter-associated urinary tract infections (CAUTIs), which are common healthcare-associated infections.

B. Administering medications through an NG tube: While NG tubes can introduce bacteria, they are not as high-risk as urinary catheters, which provide a direct route for infection.

C. Changing a sacral wound dressing: While wounds can become infected, proper wound care techniques minimize risk. Urinary catheters pose a greater risk due to prolonged exposure to bacteria.

D. Replacing an ostomy appliance: While maintaining hygiene is important, ostomy appliances are not a major source of healthcare-associated infections compared to urinary catheters.

A. Provide the client with a bedpan to reduce ambulating to the restroom B. Administer pain medications sparingly in order to minimize any cognitive side effects C. Place the client in a shared room with a client who is stable and oriented D. Orient the client to the room and environment upon admission

Correct Answer is D

Explanation

A. Provide the client with a bedpan to reduce ambulating to the restroom: While limiting unnecessary movement can help prevent falls, using a bedpan is not the best intervention unless the patient is completely immobile.

B. Administer pain medications sparingly in order to minimize any cognitive side effects: Undertreating pain can lead to restlessness and unsteady movement, which may increase fall risk rather than prevent it.

C. Place the client in a shared room with a client who is stable and oriented: Roommate selection does not directly reduce fall risk. A shared room does not guarantee supervision or fall prevention.

D. Orient the client to the room and environment upon admission: Older adults may be disoriented in a new environment, increasing fall risk. Orienting them to the room (call light, bathroom location, bed height) helps them move safely.

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The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

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Naxlex Comprehensive Predictor Exams

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