A practical nurse is preparing to provide oral hygiene to a client who remains unconscious following a prolonged surgical procedure. Arrange the following actions in the chronological order they must be performed to maintain client safety. (Assume hand hygiene and donning of gloves are complete.)
- 1Position the client in a side-lying position facing the nurse.
- 2Place a waterproof pad or towel under the client's head and an emesis basin under the chin.
- 3Gently open the client's mouth and insert a padded tongue blade to separate the teeth.
- 4Cleanse the teeth, gums, and oral cavity using a moistened soft toothbrush or sponge swab.
- 5Apply a thin layer of water-soluble moisturizer to the client's lips.
Answer
The correct sequence prioritizes airway safety: position the client side-lying, place protective linens/basin, safely open the mouth with a tongue blade, perform the oral cleansing, and finally moisturize the lips.
When providing basic care to an unconscious client, the absolute priority is maintaining a patent airway and preventing aspiration. Placing the client in a side-lying position must occur before any other step. After safety is established, the nurse protects the bed and clothing, safely gains access to the mouth to avoid reflex injuries, performs the actual cleansing, and completes the procedure by applying moisturizer for comfort.
Step-by-Step Solution
Key Concept
Prioritization of Airway Protection During Basic Care
Estimated Time:1m 30s