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. To increase blood flow to the wound site: While debridement may indirectly help improve blood flow by removing barriers to healing, its primary purpose is not to increase blood flow. Increased blood flow is a result of improved wound bed conditions rather than the main goal of the procedure.

B. To remove necrotic tissue to promote healing: The primary purpose of wound debridement is to remove necrotic (dead) or devitalized tissue from the wound bed. This process promotes healing by creating a clean wound environment, facilitating granulation tissue formation, and reducing the risk of infection, making this option the most accurate.

C. To apply antibiotics directly to the wound: While antibiotics may be part of the overall wound care plan, debridement itself is not intended for the direct application of antibiotics. The focus is on removing non-viable tissue rather than applying medications during the procedure.

D. To prevent scar formation: While proper wound care, including debridement, can help improve healing outcomes and potentially minimize scarring, the primary aim of debridement is not to prevent scars. Scarring is influenced by multiple factors, including the type of wound, depth, and individual healing responses.

A. Bright red, bloody fluid B. Thick, green fluid C. Clear, watery fluid with a pale yellow tint D. Milky, white fluid

Correct Answer is C

Explanation

A. Bright red, bloody fluid: Bright red fluid indicates fresh blood, which is typically seen in the initial drainage from a surgical site or in cases of active bleeding. This type of drainage is not characteristic of serous fluid and may suggest a complication that requires further assessment.

B. Thick, green fluid: Thick, green fluid often indicates the presence of infection or pus, which would be classified as purulent drainage rather than serous. Serous drainage should not have a thick consistency or a green color, as this would suggest an inflammatory process or infection.

C. Clear, watery fluid with a pale yellow tint: This describes serous drainage, which is typically light in color and has a watery consistency. Serous fluid is a normal finding in the early stages of wound healing, as it contains plasma and does not indicate infection or excessive bleeding.

D. Milky, white fluid: Milky or cloudy fluid can indicate the presence of chyle (lymphatic fluid) or infection, which is not characteristic of serous drainage. Serous fluid should not appear milky, as this would suggest a different underlying issue that may need to be investigated further.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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