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

Full-thickness tissue loss extending to underlying support structures such as muscle, tendon, or bone is characteristic of a stage 4 pressure ulcer, not a stage 312.
Choice B rationale
A stage 3 pressure ulcer involves full-thickness skin loss and may appear as a deep crater. There may be damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This description matches the statement in Choice B, making it the correct answer.
Choice C rationale
A shallow, ruptured or intact skin blister without slough is more indicative of a stage 2 pressure ulcer. In a stage 2 pressure ulcer, there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Choice D rationale
Unbroken skin with un-blancheable erythema is characteristic of a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin is not broken, but it has redness that does not lighten (or blanch) when you press on it.

A. Vibration B. Percussion C. Postural drainage D. Nebulization

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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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

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Correct Answer is A

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