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.
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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Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Raised toilet seats are not a safety risk for older adults. In fact, they can help prevent falls in the bathroom by reducing the distance an individual has to move to sit down and stand up from the toilet.
Choice B rationale
Throw rugs are a safety risk for older adults. They can easily cause tripping and falling, especially if the edges are not secured.
Choice C rationale
A water heater temperature of 54.4°C (130° F) is a safety risk. Water at this temperature can cause burns, especially in older adults who may have decreased sensitivity to heat.
Choice D rationale
Bathtubs with rails are not a safety risk for older adults. Rails can provide support and stability when getting in and out of the bathtub, reducing the risk of falls.
Choice E rationale
Electric cords behind furniture are a safety risk. They can be a tripping hazard and can also pose a fire risk if they are damaged.
Correct Answer is A
Explanation
Choice A rationale
Vibration is a technique used in chest physiotherapy to increase the turbulence of the client’s exhaled air. It involves the use of manual or mechanical techniques to create vibrations in the chest wall during exhalation. This helps to loosen mucus in the airways and improve clearance of secretions.
Choice B rationale
Percussion, also known as chest clapping, is a technique used in chest physiotherapy to help loosen and mobilize secretions in the lungs. However, it does not specifically increase the turbulence of exhaled air.
Choice C rationale
Postural drainage involves positioning the client in specific ways to use gravity to assist in the removal of secretions from the lungs. While it can be beneficial in managing respiratory infections, it does not directly increase the turbulence of exhaled air.
Choice D rationale
Nebulization involves the use of a machine to create a mist of medication that the client inhales into the lungs. While it can be used to deliver medications to help manage respiratory infections, it does not increase the turbulence of exhaled air.
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