A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?
Vigorously brush the client’s teeth
Turn the client to the side
Hold the toothbrush at a 90-degree angle
Place two fingers in the client’s mouth
The Correct Answer is B
Turning the client to the side can help prevent aspiration while performing oral care on an unconscious patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is b.
Choice A: SpO2 95%
The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.
Choice B: Right radial pulse regular 68/min
The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.
Choice C: Temp 36°C (96.8°F)
The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.
Choice D: BP 148/72 mm Hg
The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).
Correct Answer is D
Explanation
When caring for a client who has an irregular heart rate, the nurse should auscultate the client’s apical pulse to accurately assess their heart rate1. An electrocardiogram (ECG or EKG) may also be used to measure the timing and duration of each electrical phase in the heartbeat
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