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
The correct answer is B.
Choice A reason: Using a stiff toothbrush to clean the client’s teeth is not recommended. A stiff toothbrush can cause damage to the gums and teeth, especially in clients who may have sensitive oral tissues due to medications or medical treatments.
Choice B reason: Turning the client on his side before starting oral care is the most appropriate action. This is to prevent aspiration, especially in immobile clients who may have difficulty swallowing or clearing their throat.
Choice C reason: Using the thumb and index finger to keep the client’s mouth open is not recommended. This could be uncomfortable or even harmful for the client. Instead, a padded tongue blade could be used if necessary, but only with extreme caution and the client’s comfort in mind.
Choice D reason: Applying petroleum jelly to the client’s lips after oral care is also a good practice. This helps to prevent dryness and cracking of the lips, which can be a common problem for hospitalized patients, especially those who are dehydrated or receiving oxygen therapy. However, when compared to choice B, it is not as critical in terms of immediate safety concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer and explanation
The correct answer is choice B.
Choice A rationale:
Yoga involves gentle stretching and may not directly impact the phlebitis.
Choice B rationale:
Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition called a pulmonary embolism.
Choice C rationale:
Acupressure, like yoga, involves gentle pressure and may not directly impact the phlebitis.
Choice D rationale:
Acupuncture involves the insertion of needles and could potentially cause harm, but it is less likely to dislodge a clot than massage.
Correct Answer is A
Explanation
Choice A rationale:
Economic stability is one of the key factors of the social determinants of health (SDOH) that significantly impacts an individual's well-being. In this case, the client reporting unemployment indicates a lack of economic stability. Economic stability encompasses factors such as employment, income, and financial resources, and it can affect access to healthcare, nutrition, housing, and other social determinants of health. The client's unemployment is a challenge to their overall health.
Choice B rationale:
Neighborhood environment is another SDOH factor, which includes aspects like the quality of housing, safety, and access to parks and recreational areas. While neighborhood environment can impact health, the client's unemployment directly relates to economic stability and its challenges, making choice A the more appropriate answer.
Choice C rationale:
Education is a crucial SDOH factor, as it can influence employment opportunities, income, and health literacy. However, in this specific scenario, the client's primary concern is their unemployment. While education is a related factor, choice A (economic stability) is more directly applicable to the client's situation.
Choice D rationale:
Social and community context includes factors like social support, social norms, and community engagement. While this factor is important for overall health, the client's immediate challenge is economic stability due to unemployment. Social and community context may play a role in addressing unemployment, but it is not the factor that is currently challenging the client the most.
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