When preparing to provide mouth care to a patient who is in a coma the nurse first ensures the patient safety by doing what?

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?A. Assessing the patient’s gag reflexB. Inspecting the patient’s oral cavityC. Placing the bed in a flat positionD. Connecting the suction equipment

A. Assessing the patient's gag reflex by placing a tongue blade on the back half of the tongue reduces the risk of choking by determining the patient’s ability to swallow before mouth care is administered.

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided?A. To make the oral cavity easily accessibleB. To prevent possible musculoskeletal injuryC. To reduce plaque buildup in the mouthD. To reduce the risk of aspiration

D.An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration.

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?A. Upside down, or with the curve facing upB. Right side up, or with the curve facing downC. With the curve angled toward the patient’s left cheekD. With the curve angled toward the patient’s right cheek

A. The oral airway should be inserted upside down into the patient’s mouth, and then turned sideways and over the tongue to keep the teeth apart.

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line?A. To give the nurse a firm grip on the brush handleB. To ensure that the bristles reach all tooth surfacesC. To allow the bristles to reach beneath the gum lineD. To reduce pressure on sensitive oral tissues

C. The toothbrush is held at this angle to allow the bristles to sweep away plaque beneath the gum line.

What must the nurse avoid when brushing the tongue of an unconscious patient?A. Dislodging bacteriaB. Stimulating the gag reflexC. Moistening the oral mucosaD. Using suction

B. If the patient has a gag reflex, the nurse must be careful not to stimulate it while brushing the back of the tongue, since gagging could cause aspiration of secretions.

When preparing to clean a patient’s dentures using the sink, the nurse first protects the dentures by doing what?A. Padding the sink basin with a washclothB. Performing hand hygieneC. Filling the sink with cold waterD. Filling the sink with hot water

A.Padding the sink basin with a washcloth helps protect the patient’s dentures from being damaged during the cleaning process.

What would the nurse instruct nursing assistive personnel (NAP) to report when performing denture care for a patient?A. The amount of time it takes to clean the patient’s denturesB. The appearance of any cracks in the denturesC. Any dietary preferences of the patient that could affect the teethD. Whether the patient uses mouthwash

B. NAP are instructed to report to the nurse if the dentures have any cracks. Such damage could injure the patient’s oral cavity, and the space could become colonized with bacteria.

Under what circumstances would the nurse assume responsibility for providing denture care for a patient?A. Assessment of the oral cavity shows mucositis due to chemotherapy.B. The patient’s previous set of dentures was misplaced or thrown away.C. The dentures belong to the hospital or other facility, rather than to the patient.D. The patient is unable to care for the dentures on his or her own.

D. If a patient is unable to care for his or her dentures because of physical limitations, diminished consciousness, or other difficulties, the nurse becomes responsible for providing denture and oral care.

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized?A. After breakfast and before going to bedB. With morning careC. With morning and evening careD. After every meal and before going to bed

D. Dentures should be cleaned as often as natural teeth. The patient performs denture care at home after every meal and at bedtime, so this schedule should be maintained while the patient is hospitalized.

A patient has removed her dentures and placed them on the bedside stand. What would the nurse do to protect the patient’s dentures?A. Wrap the dentures in a paper towel.B. Store the dentures in the patient’s bedside stand, and notify other staff of where they have been placed.C. Obtain a denture cup, label it with the patient’s name, and store the dentures in a safe place.D. Wrap the dentures in a damp washcloth, and place them in a denture cup. (adsbygoogle = window.adsbygoogle || []).push({});

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness?A. Raising the patient quickly into a sitting position after completing a bed shampooB. Getting water into the patient’s ears during the rinsing phase of the shampoo C. Placing the neck in a hyperextended position during the shampoo processD. Having the entire shampooing process last longer than 15 minutes

C.Placing the neck in a hyperextended position during the shampoo process can trigger dizziness, particularly in a patient with a history of dizziness.

When preparing to help a male patient shave, why does the nurse first review the patient’s medical history?A. To determine the patient’s risk of bleedingB. To see how often he prefers to shaveC. To learn which is his dominant handD. To determine whether he can perform the task himself

Which action is most important in minimizing the patient's risk for injury when preparing to shave a patient with a history of bleeding?A. Fully explain the process to the patient in order to secure his cooperation.B. Pay particular attention to technique in order to avoid nicks and cuts.C. Ensure that the provider has ordered the intervention. D. Review current platelet count and anticoagulation studies

D. Reviewing the patient's most recent laboratory studies will give the nurse information with which to make other decisions to help ensure his safety, such as whether to use an electric razor.

Why would the nurse instruct nursing assistive personnel (NAP) to hand the patient a mirror before trimming his moustache and beard?A. To distract him so that he will stay stillB. To allow him to point out which areas he would like to have trimmedC. To promote his sense of independenceD. To keep his hands away from his face

What is the best way for the nurse to ensure that the patient is comfortable while he is being shaved?A. Administer a prescribed analgesic 30 minutes before beginning the procedure.B. Gently pull the skin taut in order to avoid nicks and cuts.C. Ask the patient if he is comfortable several times during the procedure.D. Encourage the patient to shave himself if he is capable of doing so.

For which patient would the nurse most likely ask for a podiatrist consult for nail care?A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right footB. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladderC. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floorD. A 12-year-old girl with a broken foot (adsbygoogle = window.adsbygoogle || []).push({});

A.A podiatrist should assess and develop a regular schedule of nail care for any patient with diabetes and peripheral neuropathy or vascular insufficiency. This patient is known to have diabetes, and the tingling in his foot may indicate peripheral neuropathy.

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)?A. The patient prefers that the nurse provide the care.B. NAP are not trained to perform foot care.C. The patient’s elevated risk of infection makes it unsafe for NAP to perform the care.D. The patient’s condition requires that he remain on bed rest.

C. For patients with circulatory compromise, nail and foot care cannot be delegated to NAP.

Which action would the nurse encourage an older adult with foot problems to take at home?A. Apply oval pads to treat corns.B. Wear socks made of natural fibers.C. Carefully shave off calluses with a razor blade.D. If a bandage is needed, apply gauze squares with adhesive tape.

B.Natural fibers, such as cotton, absorb perspiration and “breathe.”

In providing foot care, the nurse would soak the feet and hands of which patient?A. A 30-year-old man with type 1 diabetesB. An 86-year-old woman with generalized weaknessC. A 56-year-old patient with vascular insufficiency who was bathed the day beforeD. A 56-year-old patient with vascular insufficiency who was not bathed the day before

B. Hand and foot soaking is contraindicated in any patient with diabetes, vascular insufficiency, or peripheral neuropathy because of the inability to sense temperature and the increased risk of trauma and infection. This patient, however, has none of these conditions, and the nurse would soak her hands and feet.

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient?A. To apply moisturizer after air-drying thoroughlyB. To apply moisturizer while the skin is still wetC. To skip the moisturizerD. To towel-dry thoroughly before applying moisturizer

D. The nurse would encourage this patient to towel-dry thoroughly to impede fungal growth and prevent maceration of tissues.

When changing the soiled gown of a patient with left-sided paralysis, what will the nurse do first?A. Remove the sleeve from the weaker armB. Roll the patient into a prone positionC. Help the patient assume a side-lying positionD. Remove the sleeve from the stronger arm

D. The nurse will begin on the unaffected side to allow easier manipulation of the gown over the body part that has reduced range of motion.

When changing a patient’s gown, the nurse will place the bed in which position?A. A comfortable working height for the nurseB. A height that allows the patient full range of motionC. Locked and lowD. All side rails raised

What will the nurse do when a gown change is needed for a patient who is receiving intravenous fluids delivered by a pump?A. Document that the tubing had to be disconnected in order to change the gownB. Ask another nurse to monitor the pump during the gown changeC. Pause the infusion by pressing the sensor on the pumpD. Help the patient maintain good hygiene until the infusion is discontinued and the gown can be changed

C.The infusion is paused briefly to allow the gown to be changed.

Why must the nurse check the flow rate after changing the gown of a patient who is receiving intravenous fluids infused by gravity?A. To make sure the patient's position change has not sealed off the drip chamberB. To check whether manipulation of the intravenous container and tubing has disrupted the flow rateC. To see if an increase in the patient's heart rate has accelerated the flow rateD. To make the standard periodic flow rate adjustment

B.The nurse will check the flow rate of the infusion after a gown change because handling the intravenous tubing and container can disrupt the flow rate