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 B

Explanation

A. Celery is a low-calorie vegetable that contains some fiber (about 1.6 grams per 100 grams). While it provides some fiber, there are other options with higher fiber content.

B. Pears with their skin are an excellent source of dietary fiber. A medium-sized pear with skin provides about 5.5 grams of fiber. The skin of the pear is particularly rich in insoluble fiber, which aids in digestion and helps prevent constipation.
C. Canned pineapple generally has lower fiber content compared to fresh fruits. Most of the fiber in pineapple comes from the fruit itself, and processing can reduce the fiber content. Therefore, canned pineapple is not as high in fiber compared to other options.
D. Mashed potatoes, especially if they are peeled, are relatively low in fiber. They are primarily a starchy vegetable and do not provide significant amounts of dietary fiber unless consumed with the skin.

A. Oral mucosa B. Eye lids C. Ear lobes D. Tip of the nose

Correct Answer is A

Explanation

A. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

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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?

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