The nurse is planning to provide mouth care to an unconscious client.
Which statement is accurate for implementing mouth care to this client?

Brushing an unconscious client's teeth should be avoided.

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

Unconscious clients need less frequent mouth care than conscious clients.

Positioning the unconscious client upright is the best method because they are not eating or drinking.

Answer and Explanation

The Correct Answer is B

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

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Correct Answer is A

Explanation

The goal of the care plan should be to help the client overcome his activity intolerance related to pain.

This can be achieved by helping him to ambulate without discomfort.

Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.

Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.

Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.

A. Have the client demonstrate prescribed wound care. B. Provide written instructions in the client's native language. C. After each instruction, ask the client if he/she understands. D. Have an interpreter repeat the wound care instructions.

Correct Answer is A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

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The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is A

Explanation

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The nurse is planning to provide mouth care to an unconscious client.
Which statement is accurate for implementing mouth care to this client?