A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

Provide the client with an electric toothbrush.

Give the client an alcohol-based mouth wash.

Give the client lemon-glycerin mouth swabs.

Provide the client with a spool of dental floss.

Answer and Explanation

The Correct Answer is A

A. Provide the client with an electric toothbrush: An electric toothbrush is an appropriate option for a client with impaired upper extremity strength. It requires less physical effort to use compared to a manual toothbrush, making it easier for the client to maintain oral hygiene effectively. The powered brushing action can help ensure more thorough cleaning of the teeth and gums.

B. Give the client an alcohol-based mouth wash: Alcohol-based mouthwashes can be irritating to the oral mucosa, especially in clients who may have dry mouth or other oral health issues. Instead, a non-alcoholic mouthwash or rinse should be considered to promote comfort and effective oral care.

C. Give the client lemon-glycerin mouth swabs: Lemon-glycerin swabs are not recommended for oral care, as they can be irritating and may cause dryness in the mouth. Additionally, lemon can be acidic and potentially harm the enamel of the teeth. It is better to use products designed for sensitive oral care.

D. Provide the client with a spool of dental floss: While dental floss is important for maintaining oral hygiene, using it requires manual dexterity and strength that may be difficult for a client with impaired upper extremity strength. Instead, alternatives such as floss holders or interdental brushes could be suggested, but the initial focus should be on ensuring the client can effectively brush their teeth.

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Correct Answer is C

Explanation

A. Wear sterile gloves: Sterile gloves are not necessary for checking a pulse. Sterile gloves are typically used for procedures that involve direct contact with sterile areas or instruments. Checking a pulse does not require maintaining a sterile field, so clean gloves are sufficient.

B. Wear an N95 respirator mask: An N95 respirator mask is typically required for airborne precautions, such as those used for tuberculosis, but not for MRSA. MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces, so an N95 mask is not needed for this situation.

C. Wear clean gloves: Wearing clean gloves is the appropriate action when interacting with a client who has MRSA. This helps to prevent the transmission of bacteria and protects both the client and the nurse. Clean gloves should be used for any contact with the client or their environment to minimize the risk of spreading infection.

D. Wear protective eyewear: Protective eyewear is generally used when there is a risk of splashes or sprays of bodily fluids. In this scenario, unless there is a specific risk of such exposure during the pulse check, protective eyewear is not necessary. Clean gloves are the primary requirement for basic contact precautions with MRSA.

A. 2,4,3,1 B. 3.4.2.1 C. 4.3.2.1 D. 3.4.1.2

Correct Answer is A

Explanation

1. "The client is deteriorating, and I'm afraid the client is going to arrest." This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action. In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1).

2. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask." This statement elaborates on the clinical findings and symptoms, giving the HCP a better understanding of the patient's condition and how it is affecting their overall stability. The details about the patient's physical state, such as skin condition and oxygen saturation, highlight the critical nature of the situation.

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)." This provides the background information, including the patient's vital signs, which is critical for the HCP to evaluate the situation. Clear communication of vital signs establishes a baseline for the HCP to assess the urgency of the clinical scenario and informs potential interventions.

4. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client." This statement summarizes the recommendation, clearly indicating the action the nurse believes should be taken based on the assessment. It conveys the need for immediate evaluation and care in a higher-acuity setting, ensuring that the HCP understands the recommended next steps in the patient’s management.

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A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

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