a nurse is providing oral hygiene for an unconscious client what is the priority nursing intervention

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

A. Position the client on one side with the head turned towards you
B. Handle dentures with care
C. Use gentle brushing and flossing techniques for clients with fragile mucosa
D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

2. What is not a nursing intervention for a client with osteoporosis?

A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
B. Nurse will encourage the client to complete weight-bearing exercises
C. Nurse will encourage the client to avoid muscle strengthening exercises
D. Nurse will encourage the client to avoid repetitive movements

Correct answer: C

Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.

3. Why is traction used?

A. It allows the bones to realign
B. It decreases the risk of misalignment
C. It promotes wound healing
D. It allows the client to rest longer

Correct answer: A

Rationale: Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.

4. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

A. Once bacterial infection has caused damage, the tissue does not regenerate.
B. Once retinal detachment occurs, it does not return to its normal state.
C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.