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. A 32-year-old with menstrual cramps. Cold therapy can help relieve pain and reduce pelvic inflammation.

B. A 78-year-old with peripheral arterial disease. Cold therapy causes vasoconstriction, which can further reduce circulation in clients with PAD, increasing the risk of tissue damage.

C. A 44-year-old with a hematoma to the leg: Cold therapy is recommended for hematomas as it reduces swelling and bleeding.

D. A 69-year-old with a pulled muscle: Cold therapy reduces inflammation and numbs pain, making it beneficial for muscle injuries.

A. Protective prone B. Left lateral recumbent C. High Fowler's D. Dorsal recumbent

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.

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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

Which of the following clients should avoid the use of cold therapy?

Correct Answer is B

Explanation

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

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?

A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

A patient lives in a rural area and requires frequent appointments related to their health condition. Which of the following interventions should the nurse facilitate?

The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?

During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?