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Zorluk: ZorBasic Care and Comfort

A practical nurse is preparing to provide oral hygiene to a client who is comatose following a traumatic brain injury. Arrange the following actions in the order the nurse should perform them to ensure client safety and comfort. All options must be used.

  1. 1Position the client in a lateral position with the head turned to the side.
  2. 2Place a protective towel under the client's head and position an emesis basin under the chin.
  3. 3Gently insert a padded tongue blade to safely separate the upper and lower teeth.
  4. 4Cleanse the oral cavity using a moistened swab while applying continuous suction.
  5. 5Apply a thin layer of water-soluble lubricant to the client's lips.

Cevap

The correct sequence is to first position the client laterally, then place the towel and basin, insert the padded tongue blade, cleanse the mouth while suctioning, and finally apply lip lubricant.
When providing oral hygiene to an unconscious or comatose client, the greatest risk is aspiration of fluids or secretions into the lungs because the client lacks an intact swallowing and gag reflex. Therefore, the nurse must first turn the client to a lateral (side-lying) position so that fluids naturally drain out of the mouth. Once the airway is protected, the nurse prepares the area with a towel and basin. A padded tongue blade is then used to safely keep the mouth open without risking injury. The nurse cleans the mouth while immediately suctioning any fluids to further prevent aspiration. Finally, water-soluble lubricant is applied to protect the lips from drying and cracking.

Adım Adım Çözüm

1
Determine the highest priority action based on the client's neurological status.
Positioning the client in a lateral (side-lying) position is identified as the first and most critical step.
A comatose client lacks an intact gag reflex. Airway protection is the absolute priority; the lateral position allows fluids to drain out of the mouth by gravity, preventing aspiration.
2
Identify the preparatory steps for the procedure.
Placing a towel and emesis basin is identified as the second step.
After the client is in a safe position, the nurse protects the client's gown and bed linens from secretions and cleaning solutions.
3
Determine the safest method to access the oral cavity.
Inserting a padded tongue blade is selected as the third step.
Unconscious clients may reflexively bite down. The nurse must never insert fingers into the client's mouth. A padded tongue blade safely keeps the mouth open for cleaning.
4
Sequence the core intervention of oral care.
Cleansing the oral cavity while actively suctioning is identified as the fourth step.
Once the mouth is safely open, the nurse cleans the teeth and gums. Continuous or frequent suctioning is required to remove introduced fluids and loosened secretions.
5
Identify the final comfort measure.
Applying a water-soluble lubricant to the lips is the final step.
After the oral cavity is cleaned and secretions are removed, applying lubricant prevents drying, cracking, and potential tissue breakdown of the lips.

Anahtar Kavram

Airway protection and aspiration prevention during dependent oral care
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Konular

Basic Care and Comfort

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