While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

Provide a Yankauer tip for oral suction.

Swab the oral cavity with a washcloth.

Support the head with a small pillow.

Use oral swabs with normal saline.

Answer and Explanation

The Correct Answer is D

A. Provide a Yankauer tip for oral suction: A Yankauer suction device is useful for clearing large amounts of oral secretions but is typically used when secretions are too excessive to manage with swabbing alone. In routine oral care for an unconscious client, gentle cleaning with swabs is safer and minimizes mucosal trauma.
B. Swab the oral cavity with a washcloth: Using a washcloth in an unconscious client's mouth can be unsafe because it is bulky, can cause trauma to delicate tissues, and increases the risk of aspiration if too much fluid or debris is present. Oral swabs are designed to be safer and more appropriate for this purpose.
C. Support the head with a small pillow: While supporting the head ensures comfort, it does not directly address the priority need of safely and thoroughly cleaning the oral cavity to maintain hygiene and prevent infection. Airway protection and thorough cleaning are the primary concerns during oral care.
D. Use oral swabs with normal saline: Using oral swabs moistened with normal saline is the best intervention because it gently cleanses the mucous membranes, maintains moisture, and reduces the risk of mucosal injury. Normal saline is safe and non-irritating, which is critical for unconscious clients at risk for aspiration and mucosal breakdown.

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Correct Answer is A

Explanation

A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.

A. Spray the area with a mild periwash solution. B. Gently massage around the outside of the reddened area. C. Rinse the inflamed area with dilute hydrogen peroxide. D. Apply a thick coating of antibiotic ointment.

Correct Answer is A

Explanation

A. Spray the area with a mild periwash solution: Using a mild periwash solution gently cleanses the skin without causing additional irritation. It removes fecal material effectively while preserving skin integrity, which is crucial for preventing further breakdown in areas already inflamed.
B. Gently massage around the outside of the reddened area: Massaging near inflamed or reddened skin can worsen irritation, increase discomfort, and potentially lead to further tissue damage. Handling should be as gentle and non-traumatic as possible to promote healing.
C. Rinse the inflamed area with dilute hydrogen peroxide: Hydrogen peroxide can be too harsh for already inflamed skin and may delay healing by damaging healthy tissue. It is generally avoided for routine cleansing of delicate perineal areas.
D. Apply a thick coating of antibiotic ointment: Antibiotic ointment is not routinely indicated unless there is evidence of infection. Overuse can alter normal skin flora and may promote resistance; protecting the skin barrier with gentle cleansing and moisture barriers is preferred.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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