A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
Use gentle brushing and flossing techniques for clients with fragile mucosa
Handle dentures with care
Position the client on one side with the head turned towards you
Have a suction apparatus ready at the bedside
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect answer because Medicare is a federal health insurance program that covers certain groups of people, such as the elderly, the disabled, and the lowincome. Medicare does not publish the National Patient Safety Goals, but it does have its own quality and safety standards that health care providers must meet to receive reimbursement.
Choice B reason: This is an incorrect answer because the American Nurses Association (ANA) is a professional organization that represents the interests of registered nurses in the United States. The ANA does not publish the National Patient Safety Goals, but it does have its own code of ethics, standards of practice, and policies that guide nursing practice and promote quality and safety.
Choice C reason: This is the correct answer because the Joint Commission is an independent, nonprofit organization that accredits and certifies more than 22,000 health care organizations and programs in the United States. The Joint Commission publishes the National Patient Safety Goals, which are specific and measurable goals that address the most critical patient safety issues in health care. The Joint Commission updates the goals annually based on the latest evidence and expert input.
Choice D reason: This is an incorrect answer because the Institute of Medicine (IOM) is a division of the National Academies of Sciences, Engineering, and Medicine, which is a private, nonprofit organization that provides independent, objective, and authoritative advice to inform policy and practice. The IOM does not publish the National Patient Safety Goals, but it does conduct research and issue reports on various topics related to health and health care, including quality and safety.
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because opioids are a class of medications that act on the opioid receptors in the brain and spinal cord to reduce pain perception and emotional response. Opioids do not have a direct effect on tissue inflammation or bone healing, but they can cause side effects such as constipation, nausea, sedation, respiratory depression, and addiction.
Choice B reason: This is not the correct answer because anticoagulants are a class of medications that prevent or reduce the formation of blood clots by interfering with the clotting factors or platelets. Anticoagulants do not have a direct effect on tissue inflammation or bone healing, but they can increase the risk of bleeding and hematoma formation, which can impair the blood supply and oxygen delivery to the injured tissues.
Choice C reason: This is the correct answer because NSAIDs are a class of medications that inhibit the enzyme cyclooxygenase (COX), which is involved in the synthesis of prostaglandins, which are inflammatory mediators that cause pain, swelling, and fever. NSAIDs can decrease tissue inflammation and pain, but they can also delay bone healing by reducing the formation of osteoblasts, which are cells that build new bone tissue.
Choice D reason: This is not the correct answer because narcotics are another term for opioids, which are a class of medications that act on the opioid receptors in the brain and spinal cord to reduce pain perception and emotional response. Narcotics do not have a direct effect on tissue inflammation or bone healing, but they can cause side effects such as constipation, nausea, sedation, respiratory depression, and addiction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.