A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

Use a stiff toothbrush to clean the client's teeth.

Apply petroleum jelly to the client's lips after oral care.

Use the thumb and index finger to keep the client's mouth open.

Answer and Explanation

The Correct Answer is A

A.   This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B.   Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C.   Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D.   Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

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Correct Answer is A

Explanation

A. Atrial fibrillation is characterized by an irregularly irregular pulse. This means that the rhythm of the pulse lacks a discernible pattern; it may be irregularly fast or slow, with varying intervals between beats. Therefore, "irregular" is an appropriate term to describe the quality of the pulse in a client with atrial fibrillation.
B. While some clients with atrial fibrillation may have a slow heart rate (bradycardia), not all do. Atrial fibrillation itself typically presents with an irregular rhythm rather than a consistently slow pulse rate. Thus, "slow" may not accurately describe the quality of the pulse in atrial fibrillation.
C. "Not palpable" refers to the inability to feel or detect a pulse. In atrial fibrillation, the pulse is usually palpable but irregular. Therefore, "not palpable" would not be an accurate term to describe the pulse quality in this condition.
D. "Bounding" describes a pulse that is strong and forceful. In atrial fibrillation, the pulse may vary in strength and typically does not have a bounding quality. This term would not accurately describe the pulse quality in a client with atrial fibrillation.

A. Excessive pulmonary secretions B. Cracks in oral mucous membranes C. Tachycardia D. Poor skin turgor

Correct Answer is B

Explanation

A. Excessive pulmonary secretions can be a sign of airway irritation or infection rather than a direct adverse effect of oxygen therapy. It may warrant further assessment and intervention, but it is not typically attributed to oxygen therapy itself.
B. Dryness and cracking of oral mucous membranes can occur as a result of oxygen therapy. Oxygen delivered at higher concentrations or for prolonged periods can dry out mucous membranes, leading to discomfort and potential cracking.
C. Tachycardia (an elevated heart rate) can occur as a compensatory response to hypoxia or increased metabolic demands rather than as a direct adverse effect of oxygen therapy. However, if oxygen therapy leads to an overcorrection of hypoxemia, it could potentially contribute to changes in heart rate.
D. Poor skin turgor is typically a sign of dehydration or fluid imbalance, not directly related to oxygen therapy. It may be important to assess fluid status in clients receiving oxygen therapy, but poor skin turgor itself is not an adverse effect of oxygen administration.

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A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

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Explanation

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Correct Answer is B

Explanation

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