Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A. Use a stiff toothbrush to clean the client's teeth.
Using a stiff toothbrush is not recommended for oral care, especially for clients who may have sensitive gums or mouth tissues. A soft-bristle toothbrush or disposable foam swabs are more appropriate for gentle oral care.
B. Turn the client on his side before starting oral care.
Turning the client on his side before starting oral care is a good practice to prevent aspiration and ensure proper positioning during the procedure. This allows any excess fluid or oral care products to drain out of the mouth.
C. Use the thumb and index finger to keep the client's mouth open.
Using the thumb and index finger to keep the client's mouth open can be uncomfortable and potentially harm the client's mouth. It's better to use a mouth prop or ask the client to open their mouth gently.
D. Apply petroleum jelly to the client's lips after oral care.
Applying petroleum jelly to the client's lips after oral care is a beneficial step to help moisturize and protect the lips, especially for clients who may be at risk for dryness or cracking.
This question is an excerpt from Nurse Dive's nursing test bank - RN Ati fundamental of nursing proctored exam. Take the full exam now
Full Explanation
A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.
B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.
C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.
D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.
Similar Questions
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
A. Observe client's respiratory status.
Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitor intake and output every 8 hr.
Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevate the head of the client's bed 30° to 45°.
Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Check residual volume every 4 to 6 hr.
Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.
Full Explanation
A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
A. Temperature
The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B. BP
The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C. Pulse rate
The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D. Respiratory rate
The reported respiratory rate of 18/min is within the normal range for an adult at rest.
Full Explanation
A. The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B. The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C. The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D. The reported respiratory rate of 18/min is within the normal range for an adult at rest.
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube.
Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
A. To remove gastric acid that might cause dyspepsia
Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To confirm the placement of the NG tube
To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To identify delayed gastric emptying
To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance
To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.
Full Explanation
A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.