The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

Avoid using your fingers to open the mouth.

Apply moisturizer to the oral mucosa and lips.

Brush the teeth with a soft bristled toothbrush

Use a toothbrush with a suction attachment

Answer and Explanation

The Correct Answer is D

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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Correct Answer is D

Explanation

A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.

B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.

C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.

D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).

A. Chicken noodle soup with Pedialyte and tea B. Chicken broth with Jell-O and coffee. C. Vegetable broth with yogurt and apple juice. D. Tomato soup with a popsicle and water

Correct Answer is B

Explanation

A. Chicken noodle soup with Pedialyte and tea: Chicken noodle soup contains solids (noodles, vegetables, meat), which are not allowed on a clear liquid diet.

B. Chicken broth with Jell-O and coffee: Broth and Jell-O are transparent and fully liquid at room temperature, meeting clear liquid diet guidelines. As long as it is without milk or cream, coffee can be included in the diet.

C. Vegetable broth with yogurt and apple juice: Yogurt is not a clear liquid. Apple juice is okay if filtered, but yogurt makes the meal incorrect.

D. Tomato soup with a popsicle and water: Tomato soup is not clear, as it is opaque and pureed, which disqualifies it from the clear liquid diet.

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The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?

Correct Answer is B

Explanation

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