The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Auscultate breath sounds after client swallows.

Offer small sips of water through a straw.

Use a penlight to observe back of oral cavity.

Place tongue blade on back half of tongue.

Answer and Explanation

The Correct Answer is D

Choice A reason: Auscultating breath sounds after swallowing assesses lung function and aspiration risk but does not directly evaluate the gag reflex. The gag reflex, mediated by cranial nerves IX and X, is tested by stimulating the posterior pharynx. This method is indirect and less specific, as it relies on swallowing, which may not trigger the reflex in a weak client.

Choice B reason: Offering small sips of water tests swallowing but not the gag reflex specifically. Swallowing involves multiple cranial nerves, but the gag reflex requires direct stimulation of the posterior pharynx. In a lethargic client, this could risk aspiration, and it does not provide a clear assessment of the reflex needed for safe mouth care.

Choice C reason: Using a penlight to observe the oral cavity assesses structure but not function. The gag reflex requires tactile stimulation of the posterior pharynx to elicit a response. Visual inspection cannot confirm the reflex’s presence, which is critical to ensure safety during mouth care in a weak, lethargic client.

Choice D reason: Placing a tongue blade on the back half of the tongue directly stimulates the posterior pharynx, triggering the gag reflex if intact. This tests cranial nerves IX and X, ensuring the client can protect their airway during mouth care. In a lethargic client, this method is safe, specific, and essential to prevent aspiration, aligning with standard nursing practice.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Encouraging relaxation through massage may reduce agitation but does not directly prevent falls. Confusion increases fall risk, requiring environmental safety measures. Massage lacks evidence as a primary fall prevention strategy, making it less effective than alarms or bed adjustments for a confused, high-risk client.

Choice B reason: Lowering the bed height reduces fall injury risk but is less proactive than a pressure-sensitive alarm. Alarms alert staff to movement, preventing falls before they occur. Bed height adjustment is a secondary measure, as it mitigates injury rather than addressing the immediate risk of unsupervised movement.

Choice C reason: Setting up a pressure-sensitive alarm on the bed and chair alerts staff when the confused client attempts to move, preventing falls. This proactive measure addresses the high fall risk in real-time, aligning with evidence-based safety protocols. Alarms are critical for confused clients, ensuring timely intervention to maintain safety.

Choice D reason: Placing the client in a safety vest is a restraint, which is a last resort due to ethical and safety concerns. Restraints can increase agitation and injury risk in confused clients. Pressure-sensitive alarms are less invasive, promoting safety without compromising autonomy, making them the preferred fall prevention strategy.

A. Discontinue the use of the nasal cannula. B. Place padding around the cannula tubing. C. Apply lubricant to the cannula tubing. D. Decrease the flow rate to 1 L/minute.

Correct Answer is B

Explanation

Choice A reason: Discontinuing the nasal cannula risks worsening hypoxia, as the client’s oxygen saturation is 92%. The lesion is likely from tubing pressure, not oxygen delivery. Padding addresses the skin issue without compromising oxygenation, making discontinuation an inappropriate intervention that could harm the client’s respiratory status.

Choice B reason: Placing padding around the cannula tubing prevents further pressure on the zygomatic lesion, promoting skin healing. The lesion likely results from tubing friction or pressure. This intervention maintains oxygen delivery at 4 L/minute, ensuring the client’s 92% saturation is supported while addressing the skin integrity issue effectively.

Choice C reason: Applying lubricant to the cannula tubing may reduce friction but does not address pressure causing the lesion. Lubricants are more suitable for nasal dryness. Padding is more effective, as it cushions the tubing, preventing further skin breakdown while maintaining oxygen delivery for the client’s needs.

Choice D reason: Decreasing the flow rate to 1 L/minute may worsen hypoxia, as 4 L/minute maintains 92% saturation. The lesion is due to tubing pressure, not flow rate. Padding addresses the skin issue without altering oxygen therapy, making flow reduction an ineffective and potentially harmful intervention for this scenario.

View Question and Answer

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

The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) is caring for a client who is confused and at risk for falls. Which action should the nurse instruct the UAP to implement?

Correct Answer is C

Explanation

The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

Correct Answer is B

Explanation

After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

The nurse is caring for a client who wears bilateral hearing aids. Which action should the nurse take when communicating with the client?

The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which description(s) warrant additional follow-up by the nurse? (Select all that apply)

After a client voids, 150 ml of residual urine is noted. Which nursing problem should be included in the client’s plan of care?

A client arrives to a clinic appointment reporting sexual dysfunction for the past three months. Which condition should the nurse expect to see in the client’s medical record?

The nurse has agreed to serve as a client’s advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, which action is essential for the nurse to take?

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?