The nurse is providing oral care for a client who is unconscious. To safely perform the task, which action should the nurse take?

Raise the head of bed to 45 degrees.

Don sterile gloves prior to performing oral care.

Avoid contact with the roof of the mouth.

Place the client in a side-lying position.

Answer and Explanation

The Correct Answer is D

Choice A reason: Raising the head of the bed to 45 degrees increases aspiration risk in unconscious clients, as fluids may pool in the throat. Side-lying positioning allows drainage, ensuring safety during oral care. This contradicts aspiration prevention, per oral hygiene and unconscious patient care standards.

Choice B reason: Donning sterile gloves is unnecessary, as oral care requires clean gloves to prevent infection. Sterile gloves are for invasive procedures, not oral hygiene. Side-lying positioning prioritizes safety by reducing aspiration, per infection control and oral care protocols for unconscious clients in nursing practice.

Choice C reason: Avoiding the roof of the mouth is impractical, as thorough oral care requires cleaning all surfaces. Side-lying positioning prevents aspiration, the primary risk in unconscious clients. This focus is irrelevant to safety, per oral hygiene and aspiration prevention standards in critical care nursing.

Choice D reason: Placing the client in a side-lying position is critical, as it allows oral secretions and cleaning fluids to drain, preventing aspiration in unconscious clients. This ensures airway safety during oral care, aligning with evidence-based practice and aspiration prevention protocols in nursing care for unconscious patients.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Reviewing pain medications is premature without confirming the cause of grimacing. Pain activates the somatosensory cortex, but grimacing may reflect discomfort, fear, or effort, not necessarily pain. Asking the client clarifies the cause, ensuring appropriate intervention, as medication may be unnecessary if grimacing stems from non-pain issues.

Choice B reason: Asking the client about the grimacing clarifies its cause, as pain denial may reflect cultural or psychological factors. Grimacing involves facial muscle activation, signaling discomfort or effort, processed by the brain’s pain matrix. Direct inquiry ensures accurate assessment, guiding whether pain management or other interventions are needed, making this the first step.

Choice C reason: Administering PRN pain medication without confirming pain risks inappropriate treatment. Grimacing may indicate effort or anxiety, not pain, as denial suggests. Pain medications affect opioid receptors, but unnecessary use can cause sedation or respiratory depression. Asking the client first ensures the intervention matches the underlying issue, avoiding harm.

Choice D reason: Monitoring nonverbal behavior is useful but delays addressing the observed grimacing. Pain or discomfort triggers facial expressions via the limbic system, but denial requires clarification. Asking the client directly provides immediate insight into the cause, enabling targeted care, whereas ongoing observation may miss opportunities for timely intervention.

A. Observe skin under the breasts. B. Palpate mucus membranes for cracks. C. Assess skin folds of perineal area. D. Monitor color of nailbeds. E. Check skin for unusual bruising.

Correct Answer is ["A","C"]

Explanation

Choice A reason: Observing skin under the breasts is critical, as overweight clients with diaphoresis are prone to moisture accumulation in skin folds, fostering fungal or bacterial growth (e.g., Candida). Excess sweat increases skin pH, promoting microbial proliferation, leading to infections or irritation, requiring assessment to ensure skin integrity and prevent complications.

Choice B reason: Palpating mucous membranes for cracks assesses dehydration, not directly related to diaphoresis or obesity. Diaphoresis causes external moisture, increasing infection risk in skin folds, not mucosal dryness. Dehydration would reduce sweat, but this client’s issue is excess perspiration, making this assessment irrelevant for personal care needs.

Choice C reason: Assessing perineal skin folds is essential, as diaphoresis in overweight clients causes moisture buildup, increasing risks of fungal infections or dermatitis. Sweat alters skin microflora, promoting pathogens like Staphylococcus. Regular inspection ensures early detection of redness or breakdown, critical for maintaining skin health and preventing secondary infections.

Choice D reason: Monitoring nailbed color assesses oxygenation or circulation, unrelated to diaphoresis or obesity. Diaphoresis leads to skin fold moisture, not systemic hypoxia. Nailbed pallor might indicate anemia, but this client’s issue is localized skin infection risk, making nailbed assessment unnecessary during personal care for diaphoresis-related concerns.

Choice E reason: Checking for bruising is unrelated to diaphoresis or obesity. Bruising suggests trauma or coagulopathy, not moisture-related skin issues. Diaphoresis increases infection risk in skin folds due to microbial growth in moist environments, requiring focus on skin integrity, not bruising, which is irrelevant to this client’s care needs.

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The nurse is providing oral care for a client who is unconscious. To safely perform the task, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? (Select all that apply)

Correct Answer is ["A","C"]

Explanation

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