RN Nursing · Hygiene · Practice question
A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?
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use the thumb and index finger to keep the client's mouth open.
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Apply petroleum jelly to the client's lips after oral care.
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✓
Turn the client on his side before starting oral care.
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Use a stiff toothbrush to clean the client's teeth.
Answer & explanation
Correct: Turn the client on his side before starting oral care.
Turning an unresponsive client onto their side before beginning oral hygiene is the priority safety action because it uses gravity to allow fluids, secretions, and debris to drain out of the mouth rather than pool in the pharynx where they could be aspirated. Aspiration pneumonia is a serious and potentially fatal complication for clients who cannot protect their own airway, so positioning is the single most important preparatory step. A soft-bristled toothbrush or foam swab should be used rather than a stiff one, since stiff bristles can traumatize fragile gum tissue. Petroleum jelly applied to the lips is a reasonable comfort measure after oral care but is not the priority action being tested here. Using the thumb and index finger to hold the mouth open is not recommended — a padded tongue blade is the appropriate tool for this purpose, as it protects both client and nurse. Therefore, turning the client to the side before starting oral care is the correct answer because it directly prevents the life-threatening risk of aspiration.
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