The nurse is planning hygiene for an unconscious client. What action should the nurse plan to take?

Skip oral care due to unconsciousness.

Use warm water and soap for bathing.

Perform hygiene without donning gloves.

Utilize unused linens from another client.

Answer and Explanation

The Correct Answer is B

A. Skip oral care due to unconsciousness: Oral care is essential for unconscious clients to prevent mucosal breakdown, infection, and ventilator-associated complications. Skipping oral care increases the risk of bacterial overgrowth and aspiration. Consciousness level does not eliminate the need for hygiene.

B. Use warm water and soap for bathing: Warm water with mild soap promotes comfort, removes dirt and oils, and maintains skin integrity. Maintaining appropriate water temperature prevents hypothermia and enhances patient tolerance during hygiene procedures.

C. Perform hygiene without donning gloves: Gloves are necessary to protect both the client and nurse from pathogens present in body fluids or secretions. Performing hygiene without gloves increases the risk of infection transmission. Standard precautions must always be followed.

D. Utilize unused linens from another client: Using linens from another client violates infection control principles and can transmit pathogens. Each client requires their own clean linens to prevent cross-contamination.

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Correct Answer is C

Explanation

A. Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

B. Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

C. Clean a work surface and raise it to waist level: The work surface must be disinfected and positioned at or above waist level to maintain visibility and prevent contamination. Sterile fields kept below waist level are considered contaminated. Preparing the environment is the first step in sterile setup.

D. Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

A. Kussmaul respirations B. Cheyne-Stokes respirations C. Agonal breathing D. Biot's respirations

Correct Answer is B

Explanation

A. Kussmaul respirations: These are deep, rapid, and labored respirations typically associated with metabolic acidosis, such as diabetic ketoacidosis. They do not include alternating periods of apnea and hyperventilation, so they do not match the described pattern.

B. Cheyne-Stokes respirations: This breathing pattern is characterized by cyclic periods of increasing and decreasing depth of respiration, followed by temporary apnea. It commonly occurs in clients with advanced heart failure, neurological injury, or nearing end-of-life, making it consistent with hospice clients exhibiting irregular breathing.

C. Agonal breathing: Agonal respirations are irregular, gasping breaths often seen in severe hypoxia or near death. They are typically ineffective for gas exchange and not part of a regular cyclical pattern.

D. Biot's respirations: Biot’s respirations consist of groups of quick, shallow breaths followed by irregular pauses. They are usually associated with increased intracranial pressure or medullary damage rather than end-of-life breathing patterns.

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The nurse is planning hygiene for an unconscious client. What action should the nurse plan to take?

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