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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Isometric exercises typically involve pushing or pulling against a stationary object or surface. This action creates muscle tension without joint movement.

B. Using a trapeze involves lifting the body and is more related to mobility assistance rather than isometric exercise. It typically involves movement and is not considered an isometric exercise.

C. Brisk walking is a cardiovascular exercise that involves movement and does not focus on muscle contraction without movement. It improves cardiovascular fitness and endurance rather than strength through isometric contraction.

D. Active range of motion exercises involve moving joints through their full range of motion using muscle strength. This is different from isometric exercises, which involve static muscle contractions without joint movement.

A. Leave the new unit and return to the original unit B. Discuss the client's care with another nurse C. Say nothing and proceed to care for the client. D. Call the nursing supervisor to discuss the situation

Correct Answer is D

Explanation

D This action involves escalating the issue to a higher authority who can provide guidance and support. The nursing supervisor can assess the situation, provide advice on managing the critically ill client, and potentially reassign the nurse or provide additional resources.

A. This option does not address the immediate need to ensure the patient's safety and continuity of care. It's important to consider patient welfare and seek appropriate support before considering leaving the unit.

B. Discussing the client's care with another nurse could be a subsequent step, but it does not address the immediate need to ensure the nurse is qualified to provide the necessary care.

C. Proceeding without addressing the issue could jeopardize patient safety and is not ethically or professionally responsible. It's crucial to acknowledge limitations and seek appropriate assistance.

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A client requires complete care with ADL's. Before providing oral care, the nurse should assess for which of the following?

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