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Showing 14 questions, Sign in for moreWhich recommendation by the nurse to an adolescent patient with acne would be most appropriate?
Which of the following interventions would the nurse include in the plan of care when providing foot care to an older patient?
An older patient with an unsteady gait requests a tub bath. Which of the following actions would be most appropriate?
An unresponsive patient is wearing gas-permeable contact lenses. How would the nurse remove these lenses?
The nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient’s gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do?
When making an occupied bed, which of the following is most important for the nurse to do?
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? Select all that apply
The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: Select all that apply
While planning morning care, which of the following patients would have the highest priority to receive a bath first?
A patient with a malignant brain tumor requires oral care. The patient’s level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care.
Explanation
Correct order emphasizes safe positioning first, removal of prostheses, airway management if needed, and systematic cleaning (teeth then tongue), using appropriate devices (brush vs. toothette) and antiseptic agents (chlorhexidine) to lower infection risk while avoiding gag stimulation or aspiration.
Rationale for correct answers:
2. Begin by raising the bed, lowering the side rail, and positioning the patient close to the side of the bed with the head of the bed elevated to about 30 degrees: This positioning is essential for safety and accessibility. Elevating the head helps prevent aspiration and allows gravity to assist in draining fluids away from the airway.
5. Next, remove any partial plates or dentures if the patient has them: Dentures can obstruct access to the oral cavity and may pose a choking hazard if left in during care. Removing them ensures a thorough and safe cleaning process.
1. If the patient is uncooperative or has difficulty keeping their mouth open, insert an oral airway: This device helps maintain mouth opening without requiring active cooperation from the patient, which is especially important when consciousness is impaired.
3. Using a toothbrush moistened with chlorhexidine paste, clean the chewing surfaces and the inner surfaces of the teeth first: Chlorhexidine is an effective antimicrobial agent that reduces oral bacteria. Starting with the teeth targets the areas most prone to plaque and debris buildup.
6. Gently brush the tongue, being careful not to stimulate the gag reflex: Cleaning the tongue helps reduce bacterial load and improve oral hygiene, but care must be taken to avoid triggering vomiting or choking, especially in neurologically compromised patients.
4. If the patient does not have teeth, use a toothette moistened with chlorhexidine rinse to clean the oral cavity: Toothettes are soft and gentle, making them ideal for cleaning gums and other soft tissues in edentulous patients. The chlorhexidine rinse helps disinfect and maintain oral health.
Take home points
- Positioning and removing dentures come before mechanical cleaning; airway protection (oral airway, suction) is essential if needed.
- Use the appropriate cleaning tool (toothbrush vs. toothette) and be cautious with tongue manipulation to avoid triggering gag/aspiration.
The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client?
A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin?
The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client’s hearing aid?
The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client?
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