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 B
Explanation
A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.
Correct Answer is ["A","C","D"]
Explanation
A. Education may influence the communication process to a significant extent as an interpersonal variable.
B. Time can affect communication in terms of available time for interaction, but it is not specifically related to interpersonal variables.
C. Perception refers to how individuals interpret and make sense of information. It is a key interpersonal variable that can influence how a message is received and understood.
D. Gender can be an interpersonal variable that affects communication. Different genders may have different communication styles and preferences.
E. Feedback is not considered an interpersonl ariation that can affect communication
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