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 B

Explanation

A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping

A. Contact another provider. B. Withhold the treatment. C. Carry out the prescription. D. Notify the ethics committee.

Correct Answer is A

Explanation

A. If the nurse still has concerns after seeking clarification, the appropriate action is to contact another provider for a second opinion to ensure the safety and well-being of the client.
B. Withholding the treatment without further consultation may not be the best course of action.
Seeking additional input is important.
C. Carrying out the prescription despite concerns about its safety may pose risks to the client.
D. Notifying the ethics committee should be considered if there are ongoing ethical concerns or if the issue cannot be resolved through collaboration with other providers.

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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

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