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Zorluk: OrtaBasic Care and Comfort

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.)

  1. 1Position the client in a side-lying position facing the nurse.
  2. 2Place a waterproof pad or towel under the client's head and an emesis basin under the chin.
  3. 3Gently open the client's mouth and insert a padded tongue blade to separate the teeth.
  4. 4Cleanse the teeth, gums, and oral cavity using a moistened soft toothbrush or sponge swab.
  5. 5Apply a thin layer of water-soluble moisturizer to the client's lips.

Cevap

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.

Adım Adım Çözüm

1
Ensure an open and safe airway.
The client is positioned on their side.
A side-lying position uses gravity to help oral secretions and cleaning fluids drain out of the mouth, significantly reducing the risk of aspiration into the lungs.
2
Protect the client and bedding.
A towel and emesis basin are placed in position.
Gathering and placing supplies keeps the client clean, dry, and comfortable during the procedure.
3
Gain safe access to the oral cavity.
A padded tongue blade is used to separate the upper and lower teeth.
An unconscious client may have a strong involuntary bite reflex. A padded tongue blade safely keeps the mouth open without risking injury to the nurse's fingers or the client's teeth.
4
Perform the hygiene procedure.
The oral cavity is cleansed.
Thorough cleaning removes plaque and bacteria, which prevents hospital-acquired infections like pneumonia.
5
Provide final skin care.
Water-soluble moisturizer is applied to the lips.
Unconscious clients often breathe through their mouths, leading to dry and cracked lips. A water-soluble product provides safe moisture.

Anahtar Kavram

Prioritization of Airway Protection During Basic Care
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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