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Question

Difficulty: EasyBasic Care and Comfort

A nurse is preparing to provide oral hygiene to a comatose client. Arrange the following actions in the correct sequence from first to last.

  1. 1Place the client in a side-lying position.
  2. 2Place a towel under the client's head and an emesis basin under the chin.
  3. 3Gently open the client's mouth using a padded tongue blade.
  4. 4Clean the oral cavity using a moistened sponge swab.
  5. 5Suction the oral cavity to remove excess fluid and secretions.

Answer

The correct sequence prioritizes airway protection by first placing the client in a side-lying position, followed by setting up the towel and basin, opening the mouth with a padded blade, cleaning the oral cavity, and finally suctioning excess fluids.
The primary safety concern when providing oral care to an unresponsive client is maintaining airway patency and preventing aspiration. Therefore, the very first step must be placing the client in a side-lying position so fluids can naturally drain from the mouth. After the client is safely positioned, the nurse prepares the immediate environment with a towel and basin. A padded tongue blade is then used to safely separate the teeth without causing injury. Once the mouth is accessible, the nurse cleans the oral cavity. Finally, suctioning is performed to remove any residual fluids or secretions that were mobilized during cleaning.

Step-by-Step Solution

1
Place the client in a side-lying position.
The client is positioned to allow secretions to drain out by gravity.
The highest priority is to protect the airway and prevent aspiration, which is achieved by utilizing gravity in the side-lying position.
2
Place a towel under the client's head and an emesis basin under the chin.
The environment is prepared for the procedure.
This maintains the cleanliness of the client's gown and bed linens during the procedure.
3
Gently open the client's mouth using a padded tongue blade.
The oral cavity is safely accessible for cleaning.
An unresponsive client may bite down involuntarily; a padded tongue blade safely keeps the mouth open without causing trauma.
4
Clean the oral cavity using a moistened sponge swab.
The teeth, gums, and tongue are cleansed.
This removes plaque, prevents infection, and maintains the integrity of the oral mucosa.
5
Suction the oral cavity to remove excess fluid and secretions.
The oral cavity is cleared of any residual fluid.
Suctioning eliminates any pooled liquids that the comatose client cannot swallow or expectorate, further preventing aspiration.

Key Concept

Prioritization of airway patency and aspiration prevention during hygiene care for unresponsive clients.
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Topics

Basic Care and Comfort

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