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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.

B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.

C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.

D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.

A. 0.5 B. 2 C. 1 D. 5

Correct Answer is A

Explanation

The prescribed dose is 25 mg, and the available tablet strength is 50 mg. To calculate the correct dose:

25 mg ÷ 50 mg= 0.5

Answer: 0.5 tablets

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

Correct Answer is A

Explanation

Order: Metoprolol Tartrate 25 mg PO each morning Available: Metoprolol Tartrate 50 mg tablets How many tablets will you administer per dose?

Correct Answer is A

Explanation

Order: Ampicillin 1000 mg PO every 12 hours Available: Ampicillin 250 mg capsules How many capsules will you administer per day?

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