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Question

Difficulty: EasyBasic Care and Comfort

A nurse is preparing to provide oral care to a client who is comatose. Which of the following actions is the most appropriate for the nurse to take to ensure the client's safety?

  1. A
    Place the client in a supine position with the head of the bed completely flat.
  2. B
    Delegate the initial assessment of the oral mucosa to the unlicensed assistive personnel (UAP).
  3. Position the client in a side-lying position with the head turned to the side.Answer
  4. D
    Apply soft bilateral wrist restraints to prevent the client's hands from contaminating the supplies.

Answer

The most appropriate action is to position the client in a side-lying position with the head turned to the side.
The correct action is to place the comatose client in a side-lying position. Unconscious clients lack an intact gag and swallow reflex, placing them at an exceptionally high risk for aspiration. The lateral position allows fluids and oral secretions to drain out of the mouth by gravity, thereby protecting the airway and preventing life-threatening respiratory complications.

Step-by-Step Solution

1
Identify the client's level of consciousness and associated safety risks.
The client is comatose, meaning they lack a gag or swallow reflex and cannot protect their own airway from fluids.
Assessing the client's physiological status determines the specific safety interventions required during basic care procedures.
2
Determine the safest anatomical position for performing oral care.
A side-lying (lateral) position is selected for the procedure.
Gravity will facilitate the drainage of oral secretions and fluids out of the mouth, protecting the airway and preventing aspiration into the lungs.

Key Concept

Aspiration precautions and safe oral care for the unconscious client
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Topics

Basic Care and Comfort

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