A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following tasks should the nurse instruct the family to perform first?
Place the client in a side-lying position.
Clean the client's mouth with foam swabs.
Position an emesis basin under the client's chin.
Place a towel under the client's head.
The Correct Answer is A
A. Place the client in a side-lying position: Positioning the client on their side is the priority because it helps maintain airway safety and prevents aspiration during oral care. This step must be done first before beginning the cleaning process.
B. Clean the client's mouth with foam swabs: Oral cleaning is important to reduce bacterial growth and maintain comfort, but it should only be performed after the client is positioned safely to avoid aspiration.
C. Position an emesis basin under the client's chin: The emesis basin helps catch secretions and cleaning solution, but this is a supportive measure that comes after ensuring the client’s airway protection through proper positioning.
D. Place a towel under the client's head: A towel provides comfort and helps keep linens dry, but it is a secondary measure. Airway protection through positioning always takes priority before comfort and cleanliness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Please use your glucometer and show me the results.": Asking the client to demonstrate their technique provides the nurse with direct observation of how the client performs the skill. This allows the nurse to assess for errors in preparation, technique, or interpretation and ensures the client can perform self-monitoring correctly in their own home environment.
B. "Please tell me how long you have been using this glucometer.": Knowing the duration of glucometer use may provide some background information, but it does not show whether the client has the correct technique.
C. "These blood glucose results you've written down do not seem correct.": Telling the client their documented results seem wrong may come across as judgmental and could discourage openness. It also does not provide a clear assessment of the client’s ability to use the glucometer properly.
D. "Let me show you how to use this glucometer, so you can see if this is how you've been using it.": Demonstrating the procedure yourself first may help teach, but it does not initially allow the nurse to evaluate how the client is actually performing the task.
Correct Answer is C
Explanation
A. "I think you should call your friends to comfort you.": This deflects the client’s feelings and shifts responsibility to others, rather than addressing the client’s immediate emotional needs.
B. "Things are not as bad as they seem right now.": This minimizes the client’s fear and invalidates their feelings, which can prevent open communication about their concerns.
C. "It must be a very difficult time for you.": This is a therapeutic, empathetic response that acknowledges the client’s emotions and encourages them to share their fears in a supportive manner.
D. "Why are you afraid that you are going to die?": Asking "why" can sound judgmental or probing, which may make the client defensive instead of fostering trust and open discussion.
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