The practical nurse (PN) is providing oral care for a client who is unconscious. Which action should the PN take?

Use normal saline to rinse the client's mouth.

Avoid contact with the roof of the mouth.

Lower the head of the bed to 30 degrees.

Don sterile gloves prior to performing oral care.

Answer and Explanation

The Correct Answer is A

A. Use normal saline to rinse the client's mouth: Normal saline is safe, non-irritating, and helps maintain oral mucosa integrity.
B. Avoid contact with the roof of the mouth: Unnecessary; oral care includes cleaning all oral surfaces gently.
C. Lower the head of the bed to 30 degrees: This increases aspiration risk; the head should be elevated or the client positioned side-lying.
D. Don sterile gloves prior to performing oral care: Clean gloves are sufficient; sterile gloves are not required.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Obtain a specimen of urethral drainage for culture:
Symptoms suggest possible gonorrhea or chlamydia; culture needed for diagnosis and treatment guidance.

B. Identify all sexual partners in the last four days:
Partner notification is important but follows confirmed diagnosis.

C. Observe the perineal area for a chancroid-like lesion:
Chancroid presents differently; symptoms point to urethritis.

D. Assess for perineal itching, erythema, and excoriation:
These are signs of fungal infection or dermatitis, not primary concern here.

A. Notify the nursing supervisor of the appearance of the emesis. B. Advise the client to report any further vomiting to the PN. C. Determine if the client has a PRN prescription for an antiemetic. D. Assign an unlicensed assistive personnel to provide mouth care.

Correct Answer is A

Explanation

A. Notify the nursing supervisor of the appearance of the emesis:
Coffee-ground emesis indicates upper GI bleeding; requires prompt reporting for evaluation and intervention.

B. Advise the client to report any further vomiting to the PN:
Appropriate for minor issues, but not for potentially serious GI bleed.

C. Determine if the client has a PRN prescription for an antiemetic:
Masking symptoms with antiemetics without addressing cause can delay diagnosis.

D. Assign an unlicensed assistive personnel to provide mouth care:
Comfort measure, but secondary to urgent assessment and provider notification.

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The practical nurse (PN) is providing oral care for a client who is unconscious. Which action should the PN take?

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Naxlex Comprehensive Predictor Exams

A male client who had sexual intercourse with a causal partner three days ago tells the practical nurse (PN) that he is experiencing painful urination, urinary frequency, and discharge from the penis. Which action should the PN implement?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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