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Difficulty: MediumBasic Care and Comfort

An unresponsive older adult client requires comprehensive oral care during the morning hygiene routine following a massive cerebral infarction. Which action should the nurse select to ensure safe and effective care?

  1. A
    Delegate the assessment of the client's gag reflex to the unlicensed assistive personnel (UAP) prior to the procedure.
  2. B
    Position the client supine with the head of the bed elevated to a high-Fowler's position to prevent fluid pooling.
  3. Place the client in a lateral position with the head turned to the side to allow secretions to drain out of the mouth.Answer
  4. D
    Document the presence of receding, bleeding gums as a normal physiological change of aging.

Answer

The nurse should place the client in a lateral position with the head turned to the side to allow secretions to drain out of the mouth.
For an unresponsive client, the greatest risk during oral care is the aspiration of fluids into the lungs, which can lead to severe pneumonia. Placing the client in a lateral (side-lying) position with the head turned to the side allows gravity to pull cleaning fluids and oral secretions out of the mouth and safely away from the airway.

Step-by-Step Solution

1
Analyze the client's neurological status and risk factors.
The client is unresponsive following a severe stroke, indicating an absence of protective airway mechanisms such as the swallow and gag reflexes.
Understanding the client's physiological deficits is the first step in recognizing the high risk for aspiration during oral hygiene.
2
Determine the optimal physical position for the intervention.
A lateral (side-lying) position with the head turned outward is selected over a supine or high-Fowler's position.
This specific alignment prevents fluids from pooling in the back of the throat and allows gravity to safely drain liquids out of the mouth.
3
Ensure appropriate delegation and clinical assessment of the oral cavity.
The RN personally assesses the gag reflex and recognizes that any bleeding gums are signs of periodontal disease, not normal aging.
Safety assessments cannot be delegated to UAP, and age-related assumptions must not delay treatment for pathological conditions.

Key Concept

Aspiration Precautions and Safe Positioning for Unresponsive Clients
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Topics

Basic Care and Comfort

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