A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

Turn the patient on their side before starting oral care.

Apply petroleum jelly to the patient’s lips after oral care.

Use the thumb and index finger to keep the patient’s mouth open.

Use a stiff toothbrush to clean the patient’s teeth.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

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Correct Answer is B

Explanation

Choice A rationale
While manifestations of hypoglycemia are important to monitor in clients receiving insulin or oral hypoglycemic agents, they are not typically a primary concern in clients receiving TPN. TPN solutions contain dextrose, which can actually lead to hyperglycemia if not properly managed.
Choice B rationale

Monitoring the IV insertion site is crucial in clients receiving TPN. Infections and complications can occur at the site of insertion, so regular assessment is necessary. Therefore, Choice B is the correct answer.
Choice C rationale
The client’s oral intake is not a primary concern when receiving TPN, as TPN provides complete nutrition intravenously.
Choice D rationale
The height of the IV pole does not need to be monitored in clients receiving TPN. The infusion pump controls the rate of the TPN infusion.

A. 1 tablet B. 2 tablets C. 3 tablets D. 4 tablets

Correct Answer is B

Explanation

Step 1 is to determine how many tablets to administer. The client needs 650 mg of aspirin and each tablet contains 325 mg. So, the calculation is 650 mg ÷ 325 mg/tablet.
Step 2 is to perform the calculation. The result is 2 tablets.

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A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. What factors should the nurse monitor when collecting data about the client receiving this therapy?

Correct Answer is B

Explanation

A nurse is preparing to administer aspirin 650 mg PO. The available medication is aspirin 325 mg tablets. How many tablets should the nurse administer?

Correct Answer is B

Explanation

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