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Question

Difficulty: EasyBasic Care and Comfort

A practical nurse is preparing to perform oral hygiene for a client who is unconscious. To prevent aspiration, which is the most appropriate position for the nurse to place the client?

  1. Side-lying (lateral) positionAnswer
  2. B
    Supine position with the bed flat
  3. C
    High Fowler's position
  4. D
    Prone position with a pillow under the chest

Answer

Side-lying (lateral) position
Placing the unconscious client in a side-lying (lateral) position, ideally with the head turned to the side, is the safest method for performing oral care. This position uses gravity to allow saliva, water, and oral care products to drain easily out of the mouth, effectively protecting the airway and preventing aspiration.

Step-by-Step Solution

1
Identify the primary risk during oral care for an unconscious client.
The main risk is aspiration of fluids into the airway.
Unconscious clients lack a functional gag reflex and cannot actively swallow or spit out fluids.
2
Determine the position that best mitigates this risk using basic care principles.
The side-lying position uses gravity to facilitate fluid drainage.
By turning the client to the side, fluids will naturally flow out of the dependent side of the mouth rather than toward the trachea.

Key Concept

Basic Care and Comfort: Prevention of Aspiration
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Topics

Basic Care and Comfort

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