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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observe the appearance of sputum:
Hemoptysis is coughing up blood. The primary method of identifying it is by directly observing sputum color and content.
B. Watch chest expansion on inspiration:
Assesses ventilation and symmetry, but not presence of blood in sputum.
C. Determine how often the cough occurs:
Evaluates frequency but not the nature of sputum production.
D. Auscultate bilateral breath sounds:
Assesses air movement and adventitious sounds, but not the presence of blood.
Correct Answer is A
Explanation
A. Continue to auscultate the abdomen for a longer time period: Absence of bowel sounds should be confirmed after listening for 5 minutes in each quadrant before reporting.
B. Determine if client needs to empty bladder: Not related to bowel sounds.
C. Ask client to flex knees to relax the abdomen.: May relax abdomen but does not confirm bowel activity.
D. Notify charge nurse of the absence of bowel sounds: Only after confirming prolonged absence.
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