Examkin

Question

Difficulty: MediumBasic Care and Comfort

A client who is comatose due to a traumatic brain injury requires routine oral hygiene. Arrange the steps the practical nurse should take to safely provide mouth care in the correct sequence.

  1. 1Position the client in a lateral, side-lying position.
  2. 2Place a towel and an emesis basin under the client's chin.
  3. 3Insert a padded tongue blade gently between the back teeth.
  4. 4Clean the teeth, tongue, and gums using a moistened oral swab.
  5. 5Use a suction catheter to clear remaining fluids and secretions from the mouth.

Answer

The correct sequence prioritizes airway safety by first positioning the client laterally, followed by preparing the equipment, safely accessing the oral cavity, performing the cleaning, and finally removing the fluids with suction.
The sequencing of oral care for an unconscious client is strictly dictated by airway safety. Positioning the client laterally is always the first priority to prevent aspiration. Only after the airway is protected from gravity-induced pooling should the nurse prepare the linens, open the mouth safely with an instrument, perform the hygiene, and finally suction out the debris.

Step-by-Step Solution

1
Establish a safe position for the unconscious client.
The client is placed in a lateral (side-lying) position with the head turned to the side.
Because the client cannot swallow or expectorate, this position allows fluids to drain out of the mouth, preventing pulmonary aspiration.
2
Prepare the immediate area.
A towel and emesis basin are placed under the client's chin and cheek.
This protects the bed linens and provides a direct path for fluids to drain into the basin.
3
Open the oral cavity safely.
A padded tongue blade is inserted between the upper and lower back teeth.
This ensures safe access to the oral cavity without risking injury to the nurse's fingers if the client experiences an involuntary bite reflex.
4
Perform oral hygiene.
The oral cavity is thoroughly cleaned with a moistened sponge swab or soft-bristled toothbrush.
Cleaning removes plaque, bacteria, and crusts, preventing infection and maintaining the integrity of the mucous membranes.
5
Remove excess fluids.
The mouth is suctioned using a Yankauer or standard suction catheter.
Suctioning eliminates pooling fluids and loosened secretions, completing the cleaning process while continuing to protect the airway.

Key Concept

Oral Care for the Unconscious Client (Aspiration Prevention)
Rate this question

Topics

Basic Care and Comfort

More questions from this topic