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

Choice A reason: A 44yearold prescribed antibiotics for pneumonia is not at the greatest risk for pressure injury development, because he or she does not have any major risk factors for pressure injury. Pressure injury is a localized damage to the skin and underlying tissues caused by pressure, shear, friction, or moisture. Antibiotics for pneumonia do not directly affect the skin integrity or blood circulation, nor do they impair the mobility or sensation of the client.

Choice B reason: A 26yearold bedridden client with a fractured leg is at a high risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Bedridden status is a major risk factor for pressure injury, because it causes prolonged pressure on the bony prominences, such as the sacrum, heels, or hips, which can impair blood flow and oxygen delivery to the skin and tissues. However, the client's age, fracture, and mobility may mitigate some of the risk, as he or she may have better skin elasticity, wound healing, and ability to reposition.

Choice C reason: A 65yearold with hemiparesis and incontinence is at the greatest risk for pressure injury development, because he or she has multiple major risk factors for pressure injury. Age is a risk factor for pressure injury, because it causes decreased skin elasticity, thickness, and vascularity, which can affect the skin's resilience and repair. Hemiparesis is a risk factor for pressure injury, because it causes reduced mobility, sensation, and muscle mass, which can affect the client's ability to reposition, feel pain, and maintain tissue perfusion. Incontinence is a risk factor for pressure injury, because it causes moisture, irritation, and infection of the skin, which can weaken the skin barrier and delay wound healing.

Choice D reason: A 78yearold requiring assistance to ambulate with a walker is at a moderate risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Age is a risk factor for pressure injury, as explained above. However, the client's ambulation and assistance may reduce some of the risk, as he or she may have less pressure, shear, and friction on the skin and tissues, and more blood circulation and oxygen delivery.

Choice A reason: A decreased level of rheumatoid factor is not seen in clients with rheumatoid arthritis. Rheumatoid factor is an antibody that is produced by the immune system and can bind to other antibodies. A high level of rheumatoid factor indicates an autoimmune disorder, such as rheumatoid arthritis.

Choice B reason: A negative rheumatoid factor is not seen in clients with rheumatoid arthritis. A negative rheumatoid factor means that the antibody is not detected in the blood. A negative rheumatoid factor does not rule out rheumatoid arthritis, but it may suggest a different type of arthritis or another condition.

Choice C reason: A positive rheumatoid factor is seen in clients with rheumatoid arthritis. A positive rheumatoid factor means that the antibody is detected in the blood. A positive rheumatoid factor is more likely to occur in clients with rheumatoid arthritis, especially during a flareup of the disease.

Choice D reason: Factor does not change is not seen in clients with rheumatoid arthritis. Rheumatoid factor can vary over time and may change depending on the activity of the disease. Rheumatoid factor may increase during a flareup and decrease during remission.