A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Choice A reason:

Applying petroleum jelly to the client's lips after oral care helps prevent dryness and cracking but is not the primary action for ensuring safe and effective oral care. It is a supplementary step to maintain lip integrity.

Choice B reason:

Turning the client on their side before starting oral care is crucial for preventing aspiration, especially in immobile clients. This position allows any fluid or debris to drain out of the mouth rather than being inhaled, ensuring the client's airway remains clear.

Choice C reason:

Using the thumb and index finger to keep the client's mouth open is not safe or practical. A mouth prop or another appropriate device should be used to keep the mouth open to avoid injury to the nurse or client during oral care.

Choice D reason:

Using a stiff toothbrush can be too abrasive and potentially damage the client's gums and teeth. A soft-bristled toothbrush is recommended to gently and effectively clean the teeth and gums without causing harm.

Choice A reason:

Pulling the auricle upward and outward is appropriate for older children and adults but not for a 2-year-old. In young children, the ear canal is oriented differently, so this method would not effectively straighten the canal for proper eardrop administration.

Choice B reason:

Pulling the auricle down and back is the correct technique for children under three years old. This action helps straighten the ear canal, ensuring the eardrops are correctly administered into the canal and reach the affected area effectively.

Choice C reason:

Sitting the child up to insert a cotton ball into the innermost ear canal is not standard practice. Cotton balls are typically placed at the outer part of the ear canal to absorb excess drops, but it is not necessary to sit the child up specifically for this purpose.

Choice D reason:

Sitting the child up for 2 to 3 minutes after instilling drops can help the medication settle in the ear, but this is not the primary action required to straighten the ear canal for administering the drops. It can be a follow-up step but not the main technique for initial administration.