A client requires complete care with ADL's. Before providing oral care, the nurse should assess for which of the following?
Presence of pain
Presence of saliva
Gag reflex
Condition of the skin
The Correct Answer is C
C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.
A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.
B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).
D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Drug absorption refers to the process by which a drug moves from its site of administration into the bloodstream. Once absorbed into the bloodstream (systemic circulation), drugs can distribute to various tissues and exert their therapeutic effects.
A. Different routes of drug administration affect the rate and extent of absorption. Subcutaneous injections are generally absorbed more quickly than intramuscular injections due to differences in blood flow and tissue characteristics.
C. The effect of meals on drug absorption varies depending on the specific medication. Some drugs are absorbed faster on an empty stomach, while others may be absorbed better with food.
D. Mucous membranes, contrary to the statement, are relatively permeable to drugs, allowing for rapid absorption when medications are administered via buccal, sublingual, rectal, or vaginal routes.
Correct Answer is B
Explanation
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
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