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 C

Explanation

A. Hematocrit measures the percentage of red blood cells in the blood. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, resulting in an increase in hematocrit rather than a decrease. Therefore, a decreased hematocrit would not be an expected finding in fluid volume deficit.
B. Urine ketones are typically elevated in conditions where there is increased fat metabolism, such as in diabetic ketoacidosis or starvation. They are not directly related to fluid volume deficit and would not be an expected finding.
C. Urine specific gravity measures the concentration of solutes in the urine, indicating the kidney's ability to concentrate or dilute urine. In fluid volume deficit, the body conserves water, leading to increased urine concentration and higher urine specific gravity. Therefore, increased urine specific gravity is an expected finding in fluid volume deficit.
D. BUN is a measure of kidney function and protein metabolism. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, which can lead to an increase in BUN rather than a decrease. A decreased BUN would not typically be an expected finding in fluid volume deficit.

A. To promote digestion B. To regulate blood pressure C. To reduce inflammation D. To enhance the immune system

Correct Answer is A

Explanation

A. Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B. Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C. Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D. Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.

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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 for a client who has fluid volume deficit. Which of the following is an expected finding?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

Correct Answer is A

Explanation

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