Which client has the greatest need for special mouth care?

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

This is the appropriate action because it prevents the spread of infection and maintains a clean environment.

The nurse should also wear gloves and dispose of the bag properly.

Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.

Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.

Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.