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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is Choice B: A client who has a family history of breast cancer is scheduled for a mammogram.

Choice A rationale:

Receiving an influenza vaccination is an example of primary prevention, which aims to prevent the onset of disease.

Choice B rationale:

Scheduling a mammogram for a client with a family history of breast cancer is an example of secondary prevention. Secondary prevention involves the early detection and treatment of disease to reduce the impact of the disease. Mammograms help in the early detection of breast cancer, which can significantly improve treatment outcomes.

Choice C rationale:

Not scheduling tests for an asymptomatic client does not relate to secondary prevention. Secondary prevention involves screening and early detection of diseases in at-risk populations.

Choice D rationale:

Scheduling an echocardiogram for a client with heart failure is an example of tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness or injury that has lasting effects by helping patients manage long-term, complex health problems.

A. Request for assistance from the client's room. B. Send a personal text to a co-worker. C. Call the client's family member per their request. D. Take a photo of a client's incision site for learning purposes.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.

Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.

Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.

Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.

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A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

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A nurse is providing oral care for a client who is immobile.
Which of the following actions should the nurse take?