The nurse is performing a respiration assessment on her client. The nurse begins counting the respirations when the second hand on the clock is at 12. When the nurse looks at the chest of the client he is exhaling. The client then continues to inhale and exhale 9 times. When the second hand on the clock is just past 5 the patient begins to inhale. When the second hand reaches the 6 the client has not exhaled. What would the nurse record in the chart as this client’s respiratory rate?

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

A. Comatose:

A comatose state is characterized by an unarousable and unresponsive condition. Individuals in a coma do not respond to external stimuli, including shaking or calling their name.

B. Stuporous:

Stupor is a state of near-unconsciousness or insensibility. A stuporous patient may require more intense stimulation to achieve a response than someone who is lethargic.

C. Lethargic:

Lethargy is a state of drowsiness or fatigue. Lethargic patients may appear drowsy but can be awakened by gentle stimulation, such as shaking and calling their name.

D. Awake and Alert:

An awake and alert state implies full responsiveness, awareness, and orientation to the environment. The patient in the scenario does not fit this description.