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 B

Explanation

A. Protective prone: The prone position (lying on the stomach) does not allow easy enema administration and is not recommended.

B. Left lateral recumbent: The left lateral position allows gravity to assist with enema administration and helps the fluid move efficiently through the colon.

C. High Fowler's: Sitting upright does not promote proper enema flow, making it ineffective.

D. Dorsal recumbent: Lying on the back does not facilitate enema administration effectively.

A. A patient who is lying on wrinkled sheets. B. A patient who is pulled up in the bed by the nurse C. A patient who is frequently incontinent. D. A patient who is noted to have slough tissue

Correct Answer is B

Explanation

A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.

B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.

C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.

D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is on bed rest and an enema has been ordered. In what position should the nurse position the client?

Correct Answer is B

Explanation

Which of the following patients are at highest risk for developing a skin injury caused by shearing?

Correct Answer is B

Explanation

A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?

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