The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Perform oral hygiene at least every 2 hours.

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

Use alcohol-based mouth rinse with oral swab.

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

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

A. Protect the muscles of the lower extremities from atrophy:

This statement is not the primary purpose of sequential compression devices (SCDs) and compression stockings. While these devices can help maintain muscle tone by promoting blood circulation, their primary function is to prevent blood pooling and reduce the risk of deep vein thrombosis (DVT).

B. Keep the blood from pooling in lower extremities to avoid clots:

This is the correct purpose of sequential compression devices and compression stockings. They are designed to promote venous return and prevent blood from pooling in the lower extremities, thereby reducing the risk of blood clots, especially in individuals at risk for deep vein thrombosis (DVT).

C. Keep the patient from getting sores on the skin:

Preventing sores on the skin is not the primary purpose of these devices. While improved circulation may contribute to skin health, preventing skin sores is not the primary therapeutic goal of SCDs and compression stockings.

D. Keep the patient’s joints in working order:

Maintaining joint function is not the primary purpose of sequential compression devices and compression stockings. These devices primarily focus on promoting venous circulation and preventing complications related to blood pooling and clot formation.

A. Report the injury to a nurse manager B. Wash the affected area with soap and water C. Report the needle stick to infection control department D. Scrub the area with hand sanitizer for a full 2 minutes

Correct Answer is B

Explanation

A. Report the injury to a nurse manager:

While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.

B. Wash the affected area with soap and water:

This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.

C. Report the needle stick to the infection control department:

Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.

D. Scrub the area with hand sanitizer for a full 2 minutes:

Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.

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The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that sequential compression devices and compression stockings are used for which of the following?

Correct Answer is B

Explanation

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

Correct Answer is B

Explanation

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The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Which of the following interventions would best assist the nurse in breaking the chain of infection for all clients?