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 B

Explanation

A. Instruct the patient to cough and deep breathe to prevent atelectasis: While coughing and deep breathing are important post-operative interventions to prevent respiratory complications, they are not appropriate actions in the case of wound dehiscence. Encouraging coughing could exacerbate the situation by increasing intra-abdominal pressure.

B. Apply a sterile saline dressing and notify the surgeon immediately: This is the most appropriate immediate action in the event of wound dehiscence. Applying a sterile saline dressing helps protect the exposed tissue and prevent infection, while notifying the surgeon is crucial for further evaluation and intervention. Wound dehiscence is a surgical emergency that requires prompt attention.

C. Increase the patient's oral fluid intake to promote healing: While adequate hydration is important for overall recovery, it is not an immediate action to take in response to wound dehiscence. Addressing the wound itself and notifying the surgical team is the priority in this situation.

D. Apply pressure to the wound to stop any bleeding: While it is important to control bleeding, applying pressure may not be appropriate if there is significant opening or exposure of the internal structures. Instead, the focus should be on covering the wound with a sterile dressing and seeking immediate surgical intervention to assess and manage the dehiscence.

A. A 60 year old patient who is on a mechanical ventilator B. A 65 year old patient who is vegetarian and obese C. A 45 year old patient who smokes a pack of cigarettes a day D. A 70 year old patient who has a normal WBC count

Correct Answer is A

Explanation

A. A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation. Ventilated patients are susceptible to ventilator-associated pneumonia and other respiratory infections, making them more vulnerable to HAIs.

B. A 65 year old patient who is vegetarian and obese: While obesity can increase the risk for certain complications, being vegetarian does not inherently increase the risk for HAIs. This patient may have some risk factors, but they are not as significant as those associated with mechanical ventilation.

C. A 45 year old patient who smokes a pack of cigarettes a day: Smoking is a risk factor for various health issues, including respiratory infections, but it does not specifically correlate with a higher risk of HAIs in a hospitalized setting compared to a patient on a mechanical ventilator.

D. A 70 year old patient who has a normal WBC count: Although older age can increase the risk for infections, a normal white blood cell count indicates a functioning immune response. Without additional risk factors, this patient would not be considered the most at risk for developing HAIs compared to a ventilated patient.

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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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