A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Test for the presence of the client's gag reflex.

Lubricate the lips with petroleum jelly.

Place the client in the supine position.

Use a firm toothbrush for tooth and gum care.

Answer and Explanation

The Correct Answer is B

A.   Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B.   Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C.   Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D.   Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

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Correct Answer is A

Explanation

A. Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B. Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.

A. Don sterile gloves prior to the procedure. B. Lubricate 1 inch of the tip of the rectal tube prior to insertion. C. Place the client into a left Sims' position. D. Raise the enema bag if the client experiences cramping.

Correct Answer is C

Explanation

A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.

B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.

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A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?

Correct Answer is A

Explanation

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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