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 C

Explanation

A. Palpation:

Palpation involves using the hands to feel for tenderness, masses, or abnormalities in the abdomen. It is typically performed after auscultation. This helps prevent stimulating bowel activity before listening to bowel sounds.

B. The order does not matter:

In the context of abdominal assessment, the order does matter. Following a specific sequence, such as inspection, auscultation, palpation, and then percussion, is recommended to ensure a comprehensive and accurate assessment.

C. Auscultation:

Auscultation involves listening to bowel sounds using a stethoscope. It is the next step after inspection. Listening to bowel sounds before palpation helps avoid artificially stimulating bowel activity.

D. Percussion:

Percussion involves tapping the abdomen to assess for the presence of fluid or air. While less commonly performed in routine abdominal assessments, it is usually the last technique after inspection, auscultation, and palpation.

A. Evaluation B. Analysis C. Implementation D. Planning

Correct Answer is B

Explanation

A. Evaluation:

Both RNs and LPNs engage in the evaluation step of the nursing process. It involves assessing the effectiveness of the care plan and determining whether the desired outcomes have been achieved.

B. Analysis:

The analysis step involves a deeper level of critical thinking and problem-solving. It often includes a more comprehensive examination and interpretation of assessment data to develop the nursing diagnosis, a step that typically falls within the scope of practice for RNs.

C. Implementation:

Both RNs and LPNs are involved in implementing the care plan, which includes carrying out nursing interventions according to the established plan of care.

D. Planning:

Both RNs and LPNs participate in the planning phase, which involves setting goals, establishing priorities, and creating a care plan tailored to the patient's needs.

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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

During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

Correct Answer is C

Explanation

The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

Correct Answer is B

Explanation

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