A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Use a stiff toothbrush to clean the client's teeth.
Turn the client on his side before starting oral care.
Use the thumb and index finger to keep the client's mouth open.
Apply petroleum jelly to the client's lips after oral care.
The Correct Answer is B
A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.
B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.
C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.
D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Having the client wear a mask is the most appropriate precaution for safely
transporting a client with active pulmonary tuberculosis (TB) who requires airborne precautions. This helps contain potentially infectious respiratory droplets.
B. Asking the x-ray technician to come to the client's room to obtain a portable X-ray is a reasonable option, but it may not always be feasible depending on the facility's resources and policies.
C. Notifying the x-ray department that the client requires airborne precautions is an important step, but it is not sufficient on its own. The client should also wear a mask during transport.
D. Wearing a filtration mask and gloves during transport is not enough. The nurse should also ensure that the client is wearing a mask to contain respiratory secretions.
Correct Answer is B
Explanation
A. A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.
B. A footboard helps maintain the feet in a dorsiflexed position, preventing plantar flexion contractures in clients with impaired mobility. This device provides support and alignment to the lower extremities.
C. A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.
D. An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.
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