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. Malnutrition itself is not a direct cause of healthcare-associated infections (HAIs).
B. While having multiple caregivers can potentially increase the risk of transmission of infections if proper hand hygiene and infection control practices are not followed, it is not a direct cause of HAIs. Proper adherence to infection control protocols mitigates this risk.
C. Urinary catheterization is a common cause of healthcare-associated infections, particularly urinary tract infections (UTIs). Catheters provide a pathway for bacteria to enter the urinary tract, leading to infection if not managed properly or if left in place longer than necessary.
D. Chlorhexidine washes are actually used as an infection prevention measure rather than a cause of HAIs. Chlorhexidine is an antiseptic agent that is effective against a wide range of microorganisms and is used for preoperative skin cleansing, central line care, and other procedures to reduce the risk of infections.

A. Activate the device immediately after injection. B. Remove the safety device before disposal. C. Make sure the needle retracts into the barrel of the syringe. D. Pull the plastic sheath over the needle.

Correct Answer is A

Explanation

A. After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B. The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C. There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D. While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

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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

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Correct Answer is A

Explanation

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