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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement "Identifies viruses across the world" is not an accurate description of the Healthy People 2030 framework. This framework focuses on health objectives and goals for Americans, not the identification of viruses. It is designed to improve the health and well-being of people in the United States, not to identify viruses globally.
Choice C rationale:
The statement "Utilizes health data from the past 20 years" is not a primary purpose of the Healthy People 2030 framework. While it may incorporate historical health data to inform its objectives, the framework's main goal is to set health objectives for the future, not exclusively based on past data. It aims to address current and future health needs and challenges.
Choice D rationale:
The statement "Monitors nonmodifiable risk factors" does not accurately describe the main focus of the Healthy People 2030 framework. While the framework may consider various health risk factors, it primarily concentrates on setting health objectives and goals to improve the health of Americans. The monitoring of nonmodifiable risk factors is not its central purpose.
Correct Answer is B
Explanation
Choice A rationale:
Including a note in the medical record that an incident report was completed is a crucial step in documenting the event. It serves as a legal and organizational record of the incident, providing transparency and accountability. This information can be essential for tracking trends, identifying areas for improvement, and ensuring patient safety.
Choice B rationale:
Identifying other people involved with the event in the incident report is also an important step. It helps in determining who was present or responsible during the incident, which can be crucial in investigating the event and identifying potential areas for process improvement.
Choice C rationale:
Including personal opinions regarding an event in an incident report is not advisable. Incident reports should focus on factual, objective information. Personal opinions can introduce bias and subjectivity, which may not be helpful in addressing the root causes of the incident or improving the quality of care.
Choice D rationale:
Identifying the person responsible for the error in the incident report is a valid step, as it helps in assigning accountability and addressing any systemic issues that may have contributed to the error. However, it's essential to do so without assigning blame or making judgments. The emphasis should be on improving processes and preventing similar incidents in the future.
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