A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Choice A reason: Use gentle brushing and flossing techniques for clients with fragile mucosa is an important nursing intervention, but it is not the priority. Gentle brushing and flossing can help prevent plaque, gingivitis, and infection in the oral cavity, especially for clients with fragile mucosa due to dehydration, medication, or radiation. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice B reason: Handle dentures with care is an important nursing intervention, but it is not the priority. Handling dentures with care can prevent damage, loss, or misplacement of the dentures, which can affect the client's comfort, appearance, and nutrition. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice C reason: Position the client on one side with the head turned towards you is an important nursing intervention, but it is not the priority. Positioning the client on one side with the head turned towards you can facilitate the access and visibility of the oral cavity, as well as prevent the aspiration of saliva, blood, or debris. However, this intervention is not as effective as having a suction apparatus ready at the bedside.

Choice D reason: Have a suction apparatus ready at the bedside is the priority nursing intervention, because it can prevent the aspiration of saliva, blood, or debris, which can cause choking, pneumonia, or respiratory distress. Having a suction apparatus ready at the bedside can allow the nurse to quickly and safely remove any secretions or foreign materials from the oral cavity or the airway of the unconscious client.

Choice A reason: Calling a chaplain is not the priority nursing action for a client who is in critical condition and hypotensive. The chaplain may not be available or may not be able to provide adequate support to the spouse. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.

Choice B reason: Maintaining the client’s blood pressure is the priority nursing action for a client who is in critical condition and hypotensive. The nurse should monitor the client’s vital signs, administer fluids and medications, and provide oxygen as ordered. This choice addresses the client’s urgent medical needs and may prevent further complications.

Choice C reason: Providing the spouse a chair is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not want to sit down or may not be able to stay calm. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.

Choice D reason: Asking the client’s spouse to explain what happened is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not be able to recall or communicate the details of the event. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.